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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003623
Report Date: 07/16/2021
Date Signed: 07/16/2021 10:47:06 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:ROYAL GARDENS ELDER CAREFACILITY NUMBER:
347003623
ADMINISTRATOR:DIZON, SHIRLEY V.FACILITY TYPE:
740
ADDRESS:10812 GLENHAVEN WAYTELEPHONE:
(916) 631-7720
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 0DATE:
07/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Suzie DizonTIME COMPLETED:
10:46 AM
NARRATIVE
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On 7/16/21 at 9:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Royal Gardens Elder Care for the purpose of conducting a required 1 year annual inspection. LPA met with, Suzie Dizon and together conducted a tour of the home. Current Census is 0.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 100 degrees F which does not meet the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven-day non-perishable and two-day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored location for medications secure from residents.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, and Current Administrator Certificate.

Per California Code of Regulations, Title 22 the following deficiencies were cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ROYAL GARDENS ELDER CARE
FACILITY NUMBER: 347003623
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's testing of the hot water temperature, the licensee did not comply with the section cited above as the hot water temperature recorded in the resident bathroom was 100 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2021
Plan of Correction
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LPA observed staff turn up the hot water temperature. LPA will conduct a POC visit to ensutre the hot water temperature is within the approved regulations of 105 to 120 degrees F.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2021
LIC809 (FAS) - (06/04)
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