347003623-12-10-2025-27-AS-SRIN-DPH4RQ-20251218182017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 347003623
Report Date: 12/10/2025
Date Signed: 12/10/2025 10:52:10 AM

Unfounded

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
06/23/2025 and conducted by Evaluator Kimberly Viarella

COMPLAINT CONTROL NUMBER: 27-AS-20250623155209

FACILITY NAME:	ROYAL GARDENS ELDER CARE		FACILITY NUMBER:	347003623
ADMINISTRATOR:	DIZON, SHIRLEY V.		FACILITY TYPE:	740
ADDRESS:	10812 GLENHAVEN WAY		TELEPHONE:	(916) 382-4123
CITY:	RANCHO CORDOVA	STATE: CA	ZIP CODE:	95670
CAPACITY:	6	CENSUS: 4	DATE:	12/10/2025
		UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Maria "Susie" Dizon, Designee		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Staff sexually abused resident.

INVESTIGATION FINDINGS:

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On 12/10/25, Licensing Program Analyst (LPA) Kimberly Viarella made an unannounced visit to this facility to deliver the findings of this complaint investigation. LPA identified herself, stated the purpose of the visit and asked to meet with the Designated Facility Administrator. LPA met with Desingee, Susie Dizon and a brief interview followed.

Regarding the allegation: Staffed sexually abused resident.
Community Care Licensing received a report on 6/23/25 that chunks of soap were found inside a resident's (R1's) vagina while being cleaned. This complaint investigation was opened on 06/24/25. LPA learned through a review of medical records that on 06/22/25, while having a catheter placed, a 2-inch by 4-inch bar of soap fell out of R1's vagina.

A file review was conducted of all facility staff to ensure that they were appropriately background cleared.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250623155209

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: 12/10/2025

NARRATIVE

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All were found to be in compliance at the time of this investigation. Care notes for R1 were reviewed from 1/10/25 - 06/21/25 as well as R1's hospital medical records from 06/20/25 - 07/11/25. LPA did not find anything that could be related to abuse based on review of all documentation received.

Through interviews conducted, 2 individuals who knew R1 and were not employed by the facility believed that R1, due to their own "mental history" and previous behaviors, put the soap there themselves. Based on Department interviews neither of these individuals had “any concerns about Royal Gardens Elder Care or had any suspicion of staff sexually of physically abusing R1." The Department’s investigation revealed that,"R1 was placed on hospice care on 08/17/25 and based on their condition, R1 was not interviewed."

The department found the allegation, "Staffed sexually abused resident" to be UNFOUNDED. A finding of unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. There was no preponderance of evidence established during this investigation.

LPA conducted a walkthrough of the facility and observed 2 residents in the living room, one had a visitor and the other was watching TV. LPA observed 2 other residents, asleep in bed, both receiving hospice services.

There were no bars of soap observed in any of the bathrooms and the staff on duty reported that they only use liquid soap in the facility.

A case management visit will follow this one regarding the fact that R1 was able to obtain a bar of soap and that no one at the facility discovered this until the hospital reported it.

According to the California Code of Regulations, Title 22, no other deficiencies were observed or cited during today's visit. A copy of this report was provided and an exit interview conducted.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Kimberly Viarella
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025

LIC9099 (FAS) - (06/04)

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