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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 11:01:04 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:POCUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Susie DizonTIME COMPLETED:
11:30 AM
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On 7/16/21 at 10:48am, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Plan of Correction (POC) inspection to ensure the hot water temperature was increases to the correct temperature and meets Title 22 regulations. LPA met with Staff Susie Dizon and together conducted the POC inspection.

LPA Gould tested the hot water in the kitchen and recorded a hot water temperature of 111 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA Gould has cleared the POC and a POC clearance letter will be generated and provided to the facility.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was 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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