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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600075
Report Date: 04/05/2021
Date Signed: 04/05/2021 11:58:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200225160740
FACILITY NAME:NEW RIVERSHORE CARE HOMEFACILITY NUMBER:
075600075
ADMINISTRATOR:BALANCIO, AURORAFACILITY TYPE:
740
ADDRESS:23 STEELE COURTTELEPHONE:
(925) 458-4321
CITY:BAY POINTSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
04/05/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Aurora Balancio, AdministratorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee did not follow proper eviction procedures.
INVESTIGATION FINDINGS:
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On 4/05/2021 at 11:30am, Licensing Program Analyst (LPA), L. Hall had an unannounced visit via telephone to deliver the findings for the above allegation. Due to the Executive Order for shelter-in-place set forth by the Governor, LPA was not able to deliver the findings in person. LPA spoke with Aurora Balancio, Administrator, and explained the reason for the visit.

During the investigation, LPA conducted staff interviews, interviewed placement agency staff, and reviewed R1’s records. Based on the information obtained it was shown that resident wasn’t given a proper 30-day eviction notice. Documentation indicated on 2/12/2020 facility accepted R1 as a resident, then R1 was relocated to another facility on 2/18/2020.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20200225160740
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: NEW RIVERSHORE CARE HOME
FACILITY NUMBER: 075600075
VISIT DATE: 04/05/2021
NARRATIVE
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Continued from LIC9099.

Based on LPAs observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. The following deficiency was observed and cited (LIC 809-D) from California Code of Regulations, Title 22.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20200225160740
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: NEW RIVERSHORE CARE HOME
FACILITY NUMBER: 075600075
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2021
Section Cited
CCR
87224(a)
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87224 Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section... Thirty (30) days written notice to the resident is required... This requirement was not met as evidence by:
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Administrator will review section 87224 “Eviction Procedures” and ensure that proper and lawful eviction is followed. Self-certification to be submitted to CCLD by POC date.
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Based on LPA's interviews and record review Administrator did not
comply with the section cited above which poses a potential health and safety risk to the
residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3