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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003623
Report Date: 02/07/2025
Date Signed: 02/07/2025 12:29:53 PM

Document Has Been Signed on 02/07/2025 12:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 CAREFACILITY NUMBER:
347003623
ADMINISTRATOR/
DIRECTOR:
DIZON, SHIRLEY V.FACILITY TYPE:
740
ADDRESS:10812 GLENHAVEN WAYTELEPHONE:
(916) 382-4123
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 4DATE:
02/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Maria "Susie" DizonTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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On 02/07/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to conduct an annual inspection. LPA identified herself, explained the purpose of the visit, and asked to speak with the Designated Facility Administrator (DFA). LPA met with Designee, Marie "Susie" Dizon, (Administrator's Certificate, #7005561740, certificate expires on 12/16/2025) and Suzanne Dizon, Designee. A brief interview followed. The facility has initiated a change of Administrator. LPA forwarded the list of documents required or review prior to instituting this change.

The inspection began in the kitchen. All knives and sharps were locked and inaccessible to residents in care. The food supply was adequate for 2-day perishable and 7-day nonperishable. Opened packages in the refrigerator were dated appropriately.

LPA inspected the residents' 6 single occupancy bedroom and 2 staff rooms. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time. The facility's thermostat was set at 76 degrees Fahrenheit and was in compliance at the time of inspection. All common areas also had the required furniture, furnishings and lighting at the time of this inspection.

LPA noted grab bars, nonskid surfaces in the shower, soap, paper towels and trash cans with lids in the 2 bathrooms. The hot water temperature was measured at 114.8 degrees Fahrenheit and was in compliance at the time of this report. The fire extinguisher was inspected and had a purchase date of 2/07/25 and was also in compliance at the time of this report.

The LPA observed medications were stored in a locked closet adjacent to the living room and inaccessible to residents in care. Some medications were in pill packs provided by the pharmacy, others were not. LPA reviewed storage, dosing, and destruction procedures. A review of the First Aid kit by the LPA found it to be complete and in compliance.
Stephen RichardsonTELEPHONE: (916) 263-4746
Kimberly ViarellaTELEPHONE: (916) 809-5764
DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/07/2025
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The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. There was also a patio area for residents to enjoy.

LPA compared LIC 500 with Guardian Roster to ensure that all 5 staff had the necessary background clearances. All was in order at the time of inspection. LPA conducted a file review of 3 residents. LPA provided technical assistance with regard to some of the required paperwork. LPA reviewed 1 staff file and it was in compliance at the time of this inspection.

According to the California Code of Regulations, Title 22, no deficiencies were cited during today's visit. A copy of this report was provided and an exit interview conducted.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2025
LIC809 (FAS) - (06/04)
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