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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 097003692
Report Date: 08/20/2024
Date Signed: 08/20/2024 02:21:35 PM

Document Has Been Signed on 08/20/2024 02:21 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 NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:ROYAL GARDENFACILITY NUMBER:
097003692
ADMINISTRATOR/
DIRECTOR:		DIZON, MARIA SUSIEFACILITY TYPE:
740
ADDRESS:2961 WARREN LANETELEPHONE:
(916) 939-6940
CITY:EL DORADO HILLSSTATE: CAZIP CODE:
95762
CAPACITY: 6CENSUS: 3DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:59 PM
MET WITH:Caregiver Zahra NabipoorTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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On 8/20/24 Licensing Program Analyst (LPA) Lavinia Muscan arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with caregiver, Zahra Nabipoor and explained the purpose of the visit.

Caregiver and LPA toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, backyard, and common restrooms. LPA observed the facility to be clean, in good repair and odor-free and each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels. Facility has a 2-day perishable and a 7-day non-perishable amount of food and sharps to be locked. LPA observed the area used for medication to be locked and inaccessible to residents. Hot water temperature is within compliance.

LPA observed one (1) fire extinguishers, fire detectors, and carbon monoxide detectors. In the areas toured no immediate health, safety, or personal rights violations were observed.

LPA reviewed a total of two (2) resident files and one (1) staff file.

Several topics were discussed.

No deficiencies are being cited as a result of today’s inspection.

LPA requested a copy of the LIC 500, LIC610E and current liability insurance to be sent to the Department by end of the month.



Exit interview conducted and a copy of report left at the facility.
SUPERVISORS NAME: Laura Munoz
LICENSING EVALUATOR NAME: Lavinia Muscan
LICENSING EVALUATOR SIGNATURE: DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/20/2024
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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