New Rivershore Care Home

On 05/27/2025 at 3:25 PM, Licensing Program Analysts (LPAs) Y. Brown and L. Hall conducted an unannounced 1-Year Required inspection. LPAs met with Administrator, Aurora Balancio and explained the purpose of the visit. The Administrator certificate #7000305740 and expires on 03/26/2027. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPAs toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of three (3) bedrooms and one and one-half (1-1/2) bathrooms. No bodies of water was observed. A comfortable temperature is maintained at 81 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 121.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non skid mats. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 05/19/2025. Emergency Disaster Plan was last posted on 05/01/2025. First aid kit was observed to be complete. Fire drill was last conducted on 03/4/2024. Continued on LIC809. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809. LPAs reviewed four (4) resident files and 3 out of 4 resident files were incomplete. LPAs reviewed (3) staff files and 2 out of 3 staff did not have any training records. LPA observed the following deficiencies: At 3:42 PM, LPAs observed during record review that R1, R2, and R3 files were incomplete. At 3:47 PM, LPAs observed during record review that R1 and R2 had missing Hospice care plans. At 4:06 PM, LPAs observed during record review that S1, S2, and S3 had missing required training. At 4:21 PM, LPAs observed refrigerator, freezer, and cabinet that contained can and dry goods was unsanitary. At 4:26PM, LPAs observed four (4) trimmers, a bicycle, a treadmill, a shovel, a stationary bicycle, a weight bench, wire plant trellis', and motor scooter in back yard. At 4:27 PM, LPAs observed the master bedroom was missing screens on the patio door and bathroom window. At 4:33 PM, LPAs observed 2 (two) bottles of 409 Multi-surface disinfectant cleaner, 1 (one) Pine cleaner, 2 (two) bottles of bleach Clorox disinfectant, 1 (one) Lysol disinfectant and air freshener in the unlocked bathroom cabinet. LPA requested the following documents to be submitted to CCLD by 06/03/2025. LIC 308 Designation of Administrative Responsibility LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (Last page) Liability Insurance Continue to LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC 809C Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due date, and any repeat violations within 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.

On 5/22/2023 at 2:10PM, Licensing Program Analyst (LPA) L. Hall conducted an unannounced 1-Year Required inspection. LPA met with Aurora Blancio, Administrator , and explained the purpose of the visit. The Administrator certificate is pending and expired 3/26/2023. The facility’s fire clearance was approved for six (6) non-ambulatory residents. LPA toured the facility with Administrator including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of three (3) bedrooms and one and one-half (1-1/2) bathrooms. No bodies of water was observed. A comfortable temperature is maintained at 76 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 113.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. There is a minimum of 7-day supply of non-perishable and 2-day of perishable foods. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 06/20/2022. Emergency Disaster Plan was last posted on 06/22/2022. First aid kit was observed to be complete. Fire drill was last conducted on 01/5/2023. Continued on LIC809. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809. LPAs reviewed three (3) staff files. All three (3) staff did not have first aid or CPR. All four (4) residents' file were reviewed. LPA observed the following deficiencies: At 2:22PM, LPAs observed refrigerator/freezer and freezer in garage is unsanitary. At 2:25PM, LPAs observed a pair os scissors, allergy medication, a lighter, a bottle of Tylenol, and mucous medication in unlocked kitchen drawer. At 2:30PM, LPAs observed 4 cans of propane, a mattress, a bed frame, a shovel, and a drawer plastic bin in backyard passageway. At 2:45PM, LPAs observed during record review R2 and R4 do not have an current medical assessment. At 2:45PM, LPAs observed during record review none of the residents have a current appraisal needs and services plan. At 3:05PM, LPAs observed during record review none of the staff have first-aid or CPR training. LPA requested the following documents to be submitted to CCLD by 5/30/2023. Resident Roster LIC 308 Designation of Administrative Responsibility LIC 309 Administrative Organization LIC 500 Personnel Report LIC 610E Emergency Disaster Plan (9 pages) Liability Insurance Continued on LIC809C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809C. Deficiencies are cited from Title 22 California Code of Regulations (see 809D). Failure to submit proof of corrections by plan of correction due dates, and any repeat violations within 12-month period may result in civil penalties. Exit interview conducted. A copy of appeal rights and this report provided.

On 6/15//2022 at 3:35PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Aurora Balancio, Administrator , and explained the purpose of the visit. Upon entry, LPA temperature was not checked. LPA observed screening station that contained hand sanitizer and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage, and back yard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing poster. Hot water temperature in the shared residents' bathroom was measured at 105.1 .degrees Fahrenheit. Fire extinguisher was serviced on 3/20/2021. During record review, LPA observed facility has a copy of Mitigation Plan on file. LPA observed food, PPE and paper supplies are sufficient. The following forms are to be updated and submitted to CCLD by 6/22/2022 : -LIC9020 Register of facility Clients/Residents -LIC308 Designation of Administrative Responsibility Continued on LIC809C 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809. -LIC610E Emergency Disaster Plan The following deficiencies were observed. -At 3:57PM, LPA observed a knife sitting on kitchen counter. -At 3:59PM, LPA observed a pile of dirty clothing sitting on a shower chair located in the shower stall in shared bathroom. -At 4:05PM, LPA observed a shovel, pruner, bags of clothing, 3 mattresses, 2 boxes of garbage, a wheelchair with clothing in seat, 2 ladders, bed railing, and a plastic 5-drawer bin in back yard. -At 4:50PM, LPA reviewed R1's file and did not observe an order for bed rails, incomplete physician's report, missing consent form, Identification and Emergency information, TB information, theft and loss, appraisal needs and services plan, and safeguard. -At 5:00PM, LPA reviewed R2's file. The file is missing consent form, theft and loss, appraisal needs and services plan 11/14/2018, physician's report 12/11/18, and safeguard. -At 5:10PM, LPA reviewed R3's file. The is missing Identification and emergency form, consent, physician's report 9/2018, and appraisal needs and services 9/26/18. -At 5:15PM, LPA reviewed R4's file physician's report 10/20/16 and appraisal needs and services 10/1/16. -At 5:20PM, LPA reviewed R5's file physician's report 10/13/2016 and appraisal needs and services 10/1/2016. Continued on LIC809C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809C. -At 5:25PM, LPA reviewed R6's file appraisal needs and services 6/7/2017, physician's report had no signature and file is missing safeguard and consent. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

On 6/15/2022 at 6:30PM Licensing Program Analyst (LPA) L. Hall conducted an unannounced Case Management visit regarding a request of hospice services to CCLD on 6/10/2022. LPA met with Administrator, Aurora Balancio and explained the purpose of the visit. An email was received via email to LPA L. Hall on 6/10/2022, requesting a hospice waiver for one (1). LPA telephoned Staff 1 (S1) to request more documents and inquire on the resident that will be receiving hospice services. S1 stated that the resident has been receiving hospice services for two (2) weeks and the facility has another resident that has been receiving hospice services for two (2) months. S1 did not obtain a hospice care waiver for R1 or R2 from the Department before retaining residents at the facility. While LPA was conducting the annual inspection on 6/15/2022, LPA was informed that two (2) residents R3 and R4 had tested positive for COVID. S1 stated she did not report incident to CCLD. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights provided.

On 7/01/2021 at 04:30PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct an Infection Control Inspection. LPA met with Aurora Balancio, Administrator, and explained the purpose of the visit. Upon entry, LPA was not screened. LPA observed PPE located on living room table. LPA observed two (2) staff not wearing masks. COVID-19 signs were posted on front door. LPA toured facility including but not limited to common areas, bathroom, bedrooms, backyard, garage, and kitchen. LPA observed cough etiquette and physical distancing posted in the common areas. During record review, LPA observed visitors log and temperature log for both residents and staff. LPA observed facility has a copy of Mitigation Plan on file. LPA observed food, PPE, and paper supplies are sufficient. The following deficiencies were observed: -On 7/1/2021 at 4:50PM, LPA observed dirty clothing, Lysol disinfectant, and acid for cleaning in the bathroom shower. -On 7/1/2021 at 5:00PM, LPA observed Clorox bleach, Ajax, Lysol disinfectant in unlocked kitchen cabinet that was located underneath the sink. Continued on LIC809C. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 Continued from LIC809. -On 7/1/2021 at 5:15PM, LPA observed 3 ladders, 2 pair of garden sheers, and a pair of garden hedger accessible in backyard. Facility was given Technical Assistance regarding infection control guidelines and documented on LIC9102. The following deficiencies were observed (see LIC809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal rights and copy of this report provided.