Skip to main content
ReadyRule homepageReadyRule

Inspection visit

complaint

ROYAL GARDEN BOARD & CARE IIILicense 1976037472 citations on this visit
2 citations recorded

Inspector’s narrative

What the inspector wrote

The Administrator was advised that R-1 had been found at the Kaiser Hospital ER by R-1's daughter via telephone. R-1 was provided with an examination at the ER and subsequently returned to the facility on the same day. LPA Tsui and LPA Yelena Avetisyan conducted an initial investigative visit at the facility on 9/9/21. A tour of the physical plant was conducted as well as interviews with Staff and the Administrator and a review of facility records for R-1. During the tour of the physical plant the LPA's observed that two of the auditory alarms were not operational. An interview with the daughter of R-1 was conducted via telephone by LPA Tsui and LPM Miller on 9/21/21 at 8:30am. Based on the content of the interviews conducted on 9/9/21 from 2:00pm and 3:10pm and the interview with the daughter of R-1 on 9/21/21 as well as a tour of the physical plant on 9/9/21, LPA Tsui was able to substantiate the allegation that due to a lack of care and supervision by Direct Care Staff R-1 was able to leave the facility without their knowledge placing R-1 at risk. Citations issued, appeal rights provided and exit interview conducted.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 1569.317Type B

    Absentee notification plan for missing residents. Every RCFE shall,develop and comply with an absentee notification plan as part of the written record of the care the resident will receive in the facility, as described in Section 1569.80. This requirement was not met as evidenced by: Based on Observations of LPA's during records review there was no absentee notification plan in place for Resident #1 resulting in a potential risk to the health and safeth of resident(s) in care.

  • 87705(l)(2)Type A

    Care of Persons with Dementia. The following initial and continuing requirements shall be met for the licensee to lock exterior doors or perimeter fence gates: (2)The licensee shall ensure that the fire clearance includes approval of locked exterior doors or locked perimeter fence gates. This requirement was not met as evidenced by observations by LPA's that the exterior door to the bedroom of R-1 was blockaded without fire clearance approval to prevent exit resulting in an immediate threat to the health & safety of residents in care. Zerio Tollerance.

  • 87411(a)Type A

    Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by: Based on observations by LPA's and statements by Staff, R-1 was able to leave the facility without the knowledge of staff on duty indicating insufficient staffing resulting in an immediate risk to the health & safety of residents in care.

  • 87705(j)Type A

    Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by: Based on the observations of LPA's the alarm on the exit door was inoperable in Rm#6. Staff stated alarm had been in-op for a minimum of 1 week so staff disabled the alarm resulting in an immediate risk to the health & safety of residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the September 21, 2021 inspection of ROYAL GARDEN BOARD & CARE III?

This was a complaint inspection of ROYAL GARDEN BOARD & CARE III on September 21, 2021. 2 citations were issued: 2 Type A (serious).

Were any citations issued to ROYAL GARDEN BOARD & CARE III on September 21, 2021?

Yes, 2 citations were issued (2 Type A, 0 Type B). The first citation was for: "Absentee notification plan for missing residents. Every RCFE shall,develop and comply with an absentee notification plan..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLDView original report

Share this reportEmail

Next steps

If this is your facility,claim this pageand correct anything the record gets wrong. Free.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.