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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 347003623
Report Date: 09/17/2026
Date Signed: 09/17/2026 11:43:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2026 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20260110163114
FACILITY NAME:ROYAL GARDENS ELDER CAREFACILITY NUMBER:
347003623
ADMINISTRATOR:DIZON, SHIRLEY V.FACILITY TYPE:
740
ADDRESS:10812 GLENHAVEN WAYTELEPHONE:
(916) 382-4123
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 6DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Suzanne DizonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Licensee did not ensure that staff were competent to provide necessary care to residents.
Licensee did not ensure that the administrator was present at the facility to adequately supervise staff.
INVESTIGATION FINDINGS:
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On 9/17/2026 Licensing Program Analyst (LPA) Jason Lund arrived at facility to deliver complaint findings for the above allegations. LPA Lund met with staff and later with Administrator Suzanne Dizon and explained the reason for the visit. Census: 6

Staff handled resident in a rough manner- Based on videos and images obtained from a ring camera placed in the residents room show that while staff were changing the residents clothes and providing incontinent care, the resident (R1) was held down, restrained, and legs were forced open. Photo shows that resident sustained bruising from the care. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above
allegations are SUBSTANTIATED.

Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2026 and conducted by Evaluator Jason Lund
COMPLAINT CONTROL NUMBER: 27-AS-20260110163114

FACILITY NAME:ROYAL GARDENS ELDER CAREFACILITY NUMBER:
347003623
ADMINISTRATOR:DIZON, SHIRLEY V.FACILITY TYPE:
740
ADDRESS:10812 GLENHAVEN WAYTELEPHONE:
(916) 382-4123
CITY:RANCHO CORDOVASTATE:CAZIP CODE:
95670
CAPACITY:6CENSUS: DATE:
09/17/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Suzanne DizonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
3
4
5
6
7
8
9
Staff did not assist resident with care needs in a timely manner
INVESTIGATION FINDINGS:
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5
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10
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13
On 9/17/2026 licensing Program Analyst (LPA) Jason Lund arrived at facility to deliver complaint findings for the above allegation. On 9/17/2026 Licensing Program Analyst (LPA) Jason Lund arrived at facility to deliver complaint findings for the above allegations. LPA Lund met with staff and later with Administrator Suzanne Dizon and explained the reason for the visit. Census: 6

Staff did not assist resident with care needs in a timely manner- Based on interviews, documents reviewed, videos reviewed, images reviewed and observations made by the LPA, the above allegation cannot be substantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20260110163114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROYAL GARDENS ELDER CARE
FACILITY NUMBER: 347003623
VISIT DATE: 09/17/2026
NARRATIVE
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Licensee did not ensure that staff were competent to provide necessary care to residents- Based on videos and images obtained from a ring camera placed in the residents room show that while staff were changing the residents clothes and providing incontinent care, the resident (R1) was held down, restrained, and legs were forced open. Photo shows that resident sustained bruising from the care. Licensee neglected to give proper training to staff on incontinent care. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above allegations are SUBSTANTIATED.

Licensee did not ensure that the administrator was present at the facility to adequately supervise staff- Based on videos and images obtained from a ring camera placed in the residents room show that while staff were changing the residents clothes and providing incontinent care, the resident was held down, restrained, and legs were forced open. Photo shows that resident (R1) sustained bruising from the care. Based on video evidence the administrator didn’t properly training the staff on how to manage incontinent care. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above allegations are SUBSTANTIATED.



As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. An exit interview was conducted, and copies of the report and appeal rights left.

SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20260110163114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROYAL GARDENS ELDER CARE
FACILITY NUMBER: 347003623
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2026
Section Cited
CCR
80072(a)(1)
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Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons.
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The facility administrator will have training with staff on Personnal Rights and email LPA Lund a copy
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This requirement is not met as evidenced by: The resident (R1) was held down, restrained, and legs were forced open. This poses an immediate health and safety risk to residents in care.
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Type A
09/18/2026
Section Cited
CCR
8065(f)
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Personnel Requirements. All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. Direct care staff shall receive a minimum of 8 hours a year of training
S(2) does not have required training
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Administrator will have training on proper incontinent care.
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This requirement is not met as evidenced by: The resident (R1) was held down, restrained, and legs were forced open. This poses an immediate health and safety risk to 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.
SUPERVISOR'S NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20260110163114
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: ROYAL GARDENS ELDER CARE
FACILITY NUMBER: 347003623
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2026
Section Cited
CCR
80064(a)(7)
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5
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7
Administrator Qualification/Duties - (7) Ability to recruit, employ, train, and evaluate qualified staff, and to terminate employment of staff, if applicable to the facility.
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The facility staff who did the allegations were fired.
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This requirement is not met as evidenced by: The resident (R1) was held down, restrained, and legs were forced open. This poses an immediate health and safety risk to 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.
SUPERVISOR'S NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5