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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347003623
Report Date: 03/07/2024
Date Signed: 03/07/2024 03:25:33 PM


Document Has Been Signed on 03/07/2024 03:25 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:DIZON, SHIRLEY V.FACILITY TYPE:
740
ADDRESS:10812 GLENHAVEN WAYTELEPHONE:
(916) 382-4123
CITY:RANCHO CORDOVASTATE: CAZIP CODE:
95670
CAPACITY:6CENSUS: 3DATE:
03/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Marie Susie DizonTIME COMPLETED:
03:00 PM
NARRATIVE
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On 03/07/24 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, who also has her Administrator's Certificate, #6018733740. A brief interview followed. LPA forwarded the list of documents required for a change of Administrator.

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 singel occupancy bedroom and 2 staff rooms. All resident rooms had the required furniture, furnishings and lighting to be in compliance at this time.

LPA noted grab bars, nonskid surfaces in the shower, soap, paper towels and trashcans with lids in the 2 bathrooms. The hot water temperature was measured to ensure it was between 105 and 120 degrees. The fire extinguisher was last serviced on 10/02/23 by Hangtown Fire Control and was in compliance.

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.

The exterior of the building was inspected by the LPA. There were no bodies of water present and the yard was completely fenced in. One side of the fence was older than the rest and had loose posts and holes along the base. The Designee stated that their maintenance staff would be repairing it in the near future. LPA
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: ROYAL GARDENS ELDER CARE
FACILITY NUMBER: 347003623
VISIT DATE: 03/07/2024
NARRATIVE
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observed that all screens and gutters were in good repair. There was 1 storage shed with a lock that contained yard equipment and storage items. There was also a patio area for residents to enjoy.

The Designee, could not provide an LIC 500 at the time, LPA compared Guardian roster of background cleared staff to a handwritten roster supplied by the Desginee. 1 out of 4 members were not background cleared. LPA reviewed 3 resident files and 3 staff files. Both were complete and in compliance.

According to the California Code of Regulations, Title 22, the deficiencies observed during today's inspection were cited and many be found on the LIC809D page.

A copy of this report along with APPEAL RIGHTS was provided.

Exit interview.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 03/07/2024 03:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 1 out of 4 of the staff members did not have their background clearances completed and were not associated to the facility. This posed/poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/08/2024
Plan of Correction
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During visit, Designee submitted documentation to associate the unassociated staff to the roster. LPA emphasized and Designee understood that this person cannot work until they are cleared.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 8


Document Has Been Signed on 03/07/2024 03:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on a tour of the exterior of the facility, the licensee did not comply with the section cited above when the LPA observed the broken fence in the backyard, the debris stored on the side of the shed, and the side gate that required someone else to open because it stuck. These concerns poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2024
Plan of Correction
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Designee stated that all repairs will be completed by 04/02/24 and that a photo will be submitted to Licensing at kimberly.viarella@dss.ca.gov as proof of correction.
Type B
Section Cited
CCR
87208(a)(7)(A)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to licensing ...for approval. The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended...

The Licensee did not comply with the above regulation as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited when they changed the way rooms at the facility were being used. Staff rooms were switched to resident rooms and resident rooms were swapped for staff rooms. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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The Designee will contact the Fire Department to update and confirm changes or to schedule an inspection. Any newdocuments will be be submitted to Licensing at kimberly.viarella@dss.ca.gov.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 8 of 8


Document Has Been Signed on 03/07/2024 03:25 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87421(f)
Personnel Records - All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, nterview, record review, the licensee did not comply with the section cited above when they were unable to provide an LIC 500 upon request by this department. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/07/2024
Plan of Correction
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Designee stated that she will have the LIC 500 printed and posted by white board adjacent to the kitchen. Designee witll submit the LIC 500 along with a photo to Licensing at kimberly.viarella@dss.ca.gov of the LIC 500.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Kimberly ViarellaTELEPHONE: (916) 809-5764
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2024
LIC809 (FAS) - (06/04)
Page: 7 of 8