Royal Garden

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10:03AM. The LPA was greeted by staff, informed them of the reason for the visit, and staff proceeded to notify the Licensee and Administrator. Administrator Rada Sigal arrived at 10:42AM and Licensee Sophia Labendze arrived at 11:00AM. Entrance interview conducted. Beginning at 10:17AM, the LPA and the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: Knives are stored inaccessible in a locked drawer near the sink. Cleaning supplies are stored inaccessible and locked under the sink. Medications were locked in a cabinet. Kitchen appliances were clean and in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food and water that is located in the hallway pantry and remains locked. Food in the refrigerator was observed to be properly stored with labels and dates. LPA Huynh noted required signage and postings in the Kitchen entryway. Report Continued on LIC 809-C COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which was observed to be screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. BEDROOMS/RESTROOMS: There are seven (7) total bedrooms: six (6) private resident bedrooms and one (1) staff bedroom. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens are stored in the hallway cabinets. There are five (5) total bathrooms in the facility; two (2) are designated as a shared resident/common area restroom, one (1) shared jack and jill resident restroom, one (1) private resident restroom, and one (1) private staff restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 81.1 degrees F and 108.1 degrees F. The Licensee was advised to increase the water temperature. OUTDOOR AREA: The backyard had two (2) patio areas equipped with furniture for resident and visitor use. There is one (1) driveway gate used for emergency exit which has a self-latching mechanism and remains locked with the key accessible nearby. No bodies of water noted, and exits are free of obstructions. The LPA observed a detached garage behind the facility which contained general storage and laundry machines in good condition. RECORDS: Record review began at 10:35AM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff annual training was observed to be missing the required hospice, postural support, restricted health conditions, and additional hours of general topics. Staff initial orientation training did not contain dementia, hospice, postural support, or restricted health conditions. Report Continued on LIC 809-C INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 03/21/2026. Smoke and carbon monoxide detectors were tested at 12:02PM and were operational. Two (2) fire extinguishers were observed throughout the facility and were last serviced on 04/21/2025 and 04/24/2025, which is not within compliance of maintaining annual servicing. MEDICATIONS: Medication review began at 11:42AM. Medications are centrally stored and kept inaccessible in the kitchen. Medications were observed for one (1) resident. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. It was observed that two (2) medications were not administered as prescribed. Divalproex was started on 05/24/2026 instructed to be administered twice a day. The morning administration contained one (1) dosage that should have been administered. Olanzapine was started on 05/10/2026 and instructed to be administered in the morning and noon. The morning administration contained three (3) dosages that should have been administered. The Licensee’s interview with staff did not reveal the reason for the discrepancy. Pursuant to Title 22 CA Code of Regulations and/or the Health and Safety Code, the following deficiencies were cited. Exit interview conducted. A copy of the appeal rights and report was reviewed and provided.the state’s words, verbatim · CDSS document, May 27, 2026

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 12:10PM. The LPA was greeted by staff, informed them of the reason for the visit, and staff proceeded to notify the Licensee. Licensee/Administrator Sophia Labendze arrived at 12:50PM. Entrance interview conducted. Beginning at 12:53PM, the LPA and the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: KITCHEN: The LPA observed the facility kitchen at 12:55PM. Knives are stored inaccessible in a locked drawer near the sink. Cleaning supplies are stored inaccessible and locked under the sink. Kitchen appliances were clean and in operable condition. The facility has a sufficient supply of perishable and non-perishable food, as well as emergency food and water that is located in the hallway pantry and remains locked. Hot water was tested and measured at 108 degrees F. Food in the refrigerator was observed to be properly stored with labels and dates. LPA Huynh noted required signage and postings in the Kitchen entryway. Report Continued on LIC 809-C COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which was observed to be screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. Smoke and carbon monoxide detectors were tested at 1:30PM and were operational at the time of the visit. Two fire extinguishers were observed throughout the facility and was purchased on 04/12/2025. BEDROOMS/RESTROOMS: There are seven total bedrooms; six private resident bedrooms and one staff bedroom. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Extra linens are stored in the hallway cabinets. There are five total bathrooms in the facility; two is designated as a shared resident/common area restroom, one shared jack and jill resident restroom, one private resident restroom, and one private staff restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap, paper products, and displayed hand washing signs. Hot water was tested and measured between 105.6 degrees F and 116.2 degrees F. OUTDOOR AREA: The backyard has two patio areas equipped with furniture for resident and visitor use. There is one driveway gate used for emergency exit which has a self-latching mechanism and remains locked with the key accessible nearby. No bodies of water noted, and exits are free of obstructions. The LPA observed a detached garage behind the facility which contained general storage, laundry machines, and Personal Protection Equipment. RECORDS: Record review began at 1:32PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, and consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. Report Continued on LIC 809-C MEDICATIONS: Medication review began at 2:05PM. Medications are centrally stored and kept inaccessible in the kitchen. Medications were observed for two residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 03/21/2025. No deficiencies cited. Exit interview conducted. A copy of today's report was provided.the state’s words, verbatim · CDSS document, Apr 24, 2025

Allegation investigated: Staff hit a resident resulting in an injury. Staff made inappropriate comments towards a resident.

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 10:30 a.m., the LPA met with staff and explained the reason for the visit. At 11:20 a.m., the Licensee, Sophia Labendze arrived at the facility. During the initial visit conducted on 03/13/2024 between 12:26 p.m. and 2:30 p.m., the LPA conducted a physical plant tour and conducted an interview with the Licensee. During the initial visit, the LPA also requested and obtained copies of pertinent documents. On 02/26/2025, the LPA conducted a collateral visit to interview Resident #1 (R1). On 02/26/2025, the LPA conducted a telephonic interview with R1’s family member. During todays visit between 10:38 a.m. and 11:20 a.m., the LPA conducted a physical plant tour and conducted interviews with the Licensee, three (3) residents and three (3) staff. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation: 1.) Staff hit a resident resulting in an injury. It was alleged that Staff #1 (S1) hit Resident #1’s (R1’s) forearm with a closed fist on 03/04/2024. Interview conducted with R1’s family member stated that R1 had a bruise from the alleged incident, however R1’s family member did not take a picture of the bruise since R1 was in the process of moving out of the facility. Interviews conducted with the Licensee and staff, including S1 denied the allegation and denied that any staff ever hit residents. Interview with the Licensee explained that she did not observe bruising on R1’s forearm during the time of the incident. Residents interviewed denied being treated poorly or being hit by staff. The information obtained during interviews and the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Regarding the allegation: 2.) Staff made inappropriate comments towards a resident. It was alleged that S1 made two inappropriate comments towards R1. Staff interviews, including S1 denied speaking inappropriately towards R1. Staff interviews revealed that no staff have ever heard staff be disrespectful or rude to the residents. Interviews with residents did not voice any concerns regarding staff and stated that staff are respectful towards them. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Exit interview conducted a copy of the report was provided.the state’s words, verbatim · CDSS document, Feb 26, 2025 · control 29-AS-20240312085646

Allegation investigated: Staff handled resident in a rough manner which resulted in bruising Staff did not provide adequate food service Untrained staff Staff confined resident to their room Staff do not provide drinking water for resident Staff did not meet resident’s toileting needs Staff did not provide resident with clean bed sheets

Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced subsequent complaint visit to this facility to deliver findings. At 9:05 a.m., the LPA met with staff and explained the reason for the visit. At 9:11 a.m., the LPA spoke with the Licensee, Sophia Labendze over the telephone. The Licensee authorized staff, William Vegara to sign the report. During the initial visit conducted on 12/28/2023 between 12:30 p.m. and 2:30 p.m., LPA Peraldi conducted a physical plant tour and conducted interviews with two (2) staff, three (3) residents and one (1) resident’s family member. During the initial visit, the LPA also obtained copies of pertinent documents. During a subsequent visit conducted on 3/13/2024 between 12:26 p.m. and 2:30 p.m., LPA Peraldi conducted a physical plant tour and conducted interviews with the Licensee, one (1) resident and one (1) resident’s family member. Continued on LIC 9099-C. Unsubstantiated Regarding the allegation:1.) Staff handled resident in a rough manner which resulted in bruising. It was alleged that staff handled Resident #1 (R1) in a rough manner when transferring R1 to R1’s bed which resulted in bruising. Interviews conducted with staff and the Licensee revealed that staff are very careful when transferring R1 in and out of bed. The Licensee stated that she is not sure of the origins of R1’s bruises. The Licensee stated that staff reported the bruises to her. The Licensee believes that R1’s bruises could be cause by R1’s medication. The Licensee stated that she has tried to speak to R1’s physician regarding R1’s bruises and skin condition but R1’s representative did not disclose R1’s medical information to the Licensee. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Regarding the allegation: 2.) Staff did not provide adequate food service. It was alleged that the staff serve food that is of poor quality and of low nutrition value. During physical plant tours conducted on 12/28/2023 and 3/13/2024, the LPA observed sufficient amount of perishable and non-perishable food. The LPA observed sufficient number of fruits and vegetables being served to the residents. Resident interviews did not reveal any concerns regarding the food being served. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Regarding the allegation: 3.) Untrained staff. During the course of the investigation, the LPA conducted a record review of personnel records and found all files in order. The LPA observed training documentation showing required training completed. Additionally, on 5/22/2024, LPA Urena conducted an annual visit and reviewed personnel records including first aid/CPR training, and the appropriate training and found all files were in order. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Continued on LIC 9099-C. Regarding the allegation: 4.) Staff confined resident to their room. It was alleged that R1 is confined to R1’s room. Interviews conducted with staff and the Licensee revealed that R1’s family member/ representative visits R1 every day and stays in R1’s room. Staff stated that they listen to R1’s family member/ representative routine since they do not want issues with R1’s family member/ representative. Staff stated that R1 and other residents are not confined to their rooms as they request to be in the living area or outdoor areas. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Regarding the allegation:5.) Staff do not provide drinking water for resident. During physical plant tours conducted on 12/28/2023 and 3/13/2024, the LPA observed drinkable water available to the residents in care. Resident interviews did not reveal any concerns regarding the water. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Regarding the allegation:6.) Staff did not meet resident’s toileting needs. Resident interviews did not reveal any concerns regarding staff not meeting their toileting needs. Staff interviews revealed that staff change residents diapers every 2-3 hours or when needed. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Regarding the allegation: 7.) Staff did not provide resident with clean bed sheets. During physical plant tours conducted on 12/28/2023 and 3/13/2024, the LPA observed residents’ bedrooms with clean linens. Staff interviews revealed that staff wash residents bed sheets weekly or as needed. The information obtained during the investigation did not include evidence sufficient to corroborate the allegation. 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 deemed Unsubstantiated at this time. Exit interview conducted. A copy of the report was provided.the state’s words, verbatim · CDSS document, Dec 31, 2024 · control 29-AS-20231220105331

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. The LPA met with staff and explained the reason for the visit. The staff contacted the Licensee on the phone to inform them of the visit. The licensee Sophia Labendze arrived at the facility shortly thereafter. LPA Urena explained the reason for the visit. The LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguishers to be fully charged and last serviced on 07/31/2023. At 12:55 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:31 p.m., hot water measured at 107.3 degrees Fahrenheit. Medications and first aid kit are located in a locked kitchen cabinet. Required postings are located on one of the kitchen walls. BEDROOMS: The facility is a single-story residence and consists of six (6) bedrooms and four (4) bathrooms. There is an additional room for staff use. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. All rooms had an audible signal system, which were functioning at the time doors were open. Continues on LIC-809… RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 12:45 p.m., hot water measured at 110.8 degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. OUTDOOR SPACE: The LPA observed the back patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. The garage is detached and remains inaccessible to residents. There is a washer and dryer in the garage. There are no bodies of water on the premises. The side passage way was cleared, and free of obstructions. RECORDS: Records review began at 1:03 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications review began at 1:30 p.m., medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPA reviewed the following documents: - LIC500 Personnel Report - LIC9020 Client Roster - Certificate of Liability Insurance No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.the state’s words, verbatim · CDSS document, May 22, 2024