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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600075
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:44:51 PM

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
09/17/2024 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20240917204038
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: 4DATE:
09/20/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Aurora Balancio, AdministratorTIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Illegal eviction.
INVESTIGATION FINDINGS:
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On 9/20/2024 at 2:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to conduct the 10-day initial visit and deliver complaint findings for the allegation above. LPA met with Aurora Balancio, Administrator, and explained the reason for the visit.

During the investigation LPA interviewed reporting party (RP), Staff 1 (S1), reviewed R1's file including physician's report, admission agreement, appraisal needs and services plan, and resident appraisal which LPA requested be emailed to CCLD by 8/23/2024.

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

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
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-20240917204038
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: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2024
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 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5)
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The Licensee will read regulation 87224 and submit self-certification that it has been read and she will abide going forward to CCLD by POC date.
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Based on interview and record review the Licensee did not comply with the section cited above in serving R1 with an appropriate eviction notice, which poses a potential health and safety risk to persons in care.
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A mandatory informal meeting will be held at a later time.
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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: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240917204038
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: 09/20/2024
NARRATIVE
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Continued from LIC9099.

RP stated during interview that R1 was to be discharged from Sutter Delta Hospital in Antioch on 9/16/2024, but S1 refused to let R1 return to the facility. R1 was to be discharged with the assistance of home health. S1 stated the facility is no longer able to provide the care necessary for R1 and that's why she refused. S1 stated it is hard to take care of S1 due to R1 being heavy and not listening. S1 showed LPA an invalid eviction letter that was given to R1 on 8/14/2024. R1's condition have not changed

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

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: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3