Royal Gardens Elder Care

Allegation investigated: Staff handled resident in a rough manner Licensee did not ensure that staff were competent to provide necessary care to residents. Licensee did not ensure that the administrator was present at the facility to adequately supervise staff.

On 9/17/2026 Licensing Program Analyst (LPA) Jason Lund arrived at facility to deliver complaint findings for the above allegations. LPA Lund met with staff and later with Administrator Suzanne Dizon and explained the reason for the visit. Census: 6 Staff handled resident in a rough manner- Based on videos and images obtained from a ring camera placed in the residents room show that while staff were changing the residents clothes and providing incontinent care, the resident (R1) was held down, restrained, and legs were forced open. Photo shows that resident sustained bruising from the care. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above allegations are SUBSTANTIATED. Substantiated Licensee did not ensure that staff were competent to provide necessary care to residents- Based on videos and images obtained from a ring camera placed in the residents room show that while staff were changing the residents clothes and providing incontinent care, the resident (R1) was held down, restrained, and legs were forced open. Photo shows that resident sustained bruising from the care. Licensee neglected to give proper training to staff on incontinent care. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above allegations are SUBSTANTIATED. Licensee did not ensure that the administrator was present at the facility to adequately supervise staff- Based on videos and images obtained from a ring camera placed in the residents room show that while staff were changing the residents clothes and providing incontinent care, the resident was held down, restrained, and legs were forced open. Photo shows that resident (R1) sustained bruising from the care. Based on video evidence the administrator didn’t properly training the staff on how to manage incontinent care. The Department has concluded, based on the preponderance of the evidence obtained during this investigation, that the above allegations are SUBSTANTIATED. As a result of this investigation, this LPA found the allegations to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, deficiencies were observed or cited and noted on LIC 809D. An exit interview was conducted, and copies of the report and appeal rights left.the state’s words, verbatim · CDSS document, Sep 17, 2026 · control 27-AS-20260110163114

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80072(a)(1) · Plan of correction due date: Sep 18, 2026

Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement is not met as evidenced by: The resident (R1) was held down, restrained, and legs were forced open. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: The facility administrator will have training with staff on Personnal Rights and email LPA Lund a copy

From the deficiency page — Deficiency type: Type A · Section cited: CCR 8065(f) · Plan of correction due date: Sep 18, 2026

Personnel Requirements. All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance. Direct care staff shall receive a minimum of 8 hours a year of training S(2) does not have required training This requirement is not met as evidenced by: The resident (R1) was held down, restrained, and legs were forced open. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: Administrator will have training on proper incontinent care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 80064(a)(7) · Plan of correction due date: Sep 18, 2026

Administrator Qualification/Duties - (7) Ability to recruit, employ, train, and evaluate qualified staff, and to terminate employment of staff, if applicable to the facility. This requirement is not met as evidenced by: The resident (R1) was held down, restrained, and legs were forced open. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 17, 2026

Plan of correction: The facility staff who did the allegations were fired.

Type of visit: Required - 1 Year

Licensing Program Analysts (LPAs) Christina Valerio and Reza Jamaly arrived unannounced to conduct an annual required inspection. LPAs met with Licensee Susie Dizon, and explained the purpose of the visit. LPAs toured the facility to ensure compliance with Title 22 regulations. LPAs observed four residents in care at the start of the visit. At the end of the visit, one resident moved out. LPAs inspected four (4) resident bedrooms, all of which were free from odors, fully furnished, and had no obstructions of emergency exits. LPAs observed two (2) resident bathrooms. Resident bathrooms were observed to have skid mats, shower chair, grab bars, hygiene supplies, and to be clean. The water faucet delivered hot water at a temperature of 110.1 degree F, which is within the required range of 105.0 - 120.0 degree F. The facility was observed to have an adequate food supply, and an emergency supply of canned food. LPA Valerio observed the kitchen and dinning room to be clean and sanitary. LPAs observed common areas (hallways, living room, dinning room, and sitting area) to be fully furnished and organized. LPAs observed the exterior plant. The shed in the backyard was observed to be used for storage. Exit pathways were clear from obstructions. The facility fire extinguisher was fully charged and last inspected on 02/17/2026. The date of the last fire drill was conducted on 01/10/2026. LPAs reviewed one (1) resident file and one (1) staff file. Files were observed to be up to date with required annual documentation. LPA Valerio requested the following to be sent to christina.valerio@dss.ca.gov: LIC 500, LIC 308, LIC 610, and copy of Liability Insurance Per California Code of Regulations (CCR) - Title 22 - no deficiencies were cited today. An exit interview was held, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Mar 10, 2026

Type of visit: Case Management - Other

On 01/28/26, Licensing Program Analysts (LPAs) Kimberly Viarella and Christina Valerio made an unannounced visit to this facility to conduct a case management and to deliver an amended report. LPAs identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. The Administrator was not present upon arrival, but staff contacted them and Susie Dizon arrived shortly after. During an annual inspection on 03/07/24, LPA compared Guardian roster of background cleared staff to a handwritten roster supplied by the Designee. 1 out of 4 staff members were not background cleared in Guardian and the Designee could not provide documentation showing that the 1 individual had been cleared. LPA Viarella cited the deficiency. After final printing the report, LPA Viarella learned that the individual was background cleared. This LPA contacted the facility to inform them that the civil penalty would not be assessed and that the report amended. According to the California Code of Regulations, Title 22, no other deficiencies were observed during today's visit, a copy of this report was provided along with the amended report from the visit on 03/07/24. LPA Viarella also requested the original report in return. An exit interview was conducted with Susie Dizon.the state’s words, verbatim · CDSS document, Jan 28, 2026

Type of visit: Case Management - Other

On 01/28/26 Licensing Program Analysts (LPAs) Kimberly Viarella and Christina Valerio arrived unannounced to this facility to conduct a case management visit for the purpose of delivering an Order to Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion from Facility. LPA met with Susie Dizon, Administrator, and explained the purpose of the visit. Staff members (S2), (S3), and (S4) are excluded. LPA served notice of "ORDER TO LICENSEE/FACILITY OF IMMEDIATE EXCLUSION FROM FACILITY" for S2 and S3 who was not present at the time of visit. S4 was present. Administrator was advised an immediate removal is warranted and requested the Personnel Report (LIC500) and Guardian account be updated to remove S2, S3, and S4 from the facility staff roster. A notice of completion shall be submitted to Community Care Licensing (CCL). LPA informed the Administrator that S2, S3, and S4, are not allowed to be employed and/or on any facility premises. The Order to Individual of Immediate Exclusion From All Facilities will be in effect as of 1/28/2026 upon receipt of the letter. A copy of the letter was given to Susie Dizon at the facility during this visit. The facility understands this is an Immediate Exclusion and has agreed S2, S3, and S4 cannot be allowed to work, live in, and/or have contact with clients in any residential facility licensed by the California Department of Social Services unless otherwise ordered by the Department. Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were cited during this visit. Exit interview held with Susie Dizon, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 28, 2026

Allegation investigated: Staff sexually abused resident.

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 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.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 27-AS-20250623155209

Type of visit: Case Management - Deficiencies

On 12/10/25, Licensing Program Analyst (LPA) Kimberly Viarella arrived at this facility to conduct a case management visit related to information learned during complaint investigation (#27-AS-20250623155209). LPA identified herself, stated the purpose of the visit, and asked to meet with the Designated Facility Administrator. LPA met with Designee, Susie Dizon and a brief interview followed. During the investigation, this LPA learned that while at the hospital, medical staff there found a bar of soap inside a resident's (R1's) vagina. There was no preponderance of evidence found during the investigation to indicate that staff were responsible. There was information collected during the investigation to indicate that R1 themselves may inserted the soap. R1 should have been under constant supervision while bathing / toileting as they required assistance and should not have had access to the bar of soap without supervision. This deficiency has been documented on the LIC 809D page. 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.the state’s words, verbatim · CDSS document, Dec 10, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87466 · Plan of correction due date: Dec 11, 2025

Observation of the Resident The licensee... that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided... The Licensee did not meet the above requirement as evidenced by: R1 had a bar of soap inside their vagina which was not discovered until R1 was at the hospital. This posed an immediate risk to the health, safety and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 10, 2025

Plan of correction: Designee to conduct a staff training today regarding preventing prohibited toxic/hazardous materials to be left accessible to residents in care. Designee to submit content of training and signature sheet to CCL by close of business tomorrow at CCLASCPSacrmentoSouthRO@dss.ca.gov, attention LPA Viarella.

Type of visit: Required - 1 Year

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. 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.the state’s words, verbatim · CDSS document, Feb 7, 2025

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

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 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 Designee. 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. This report was amended. 4 out of 4 individuals were background cleared. The appropriate documentation was located after this report had been final printed, the deficiency was removed and the civil penalty was not assessed.the state’s words, verbatim · CDSS document, Mar 7, 2024

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.