Royal Gardens Healthcare: Discharge Records Unsigned - CA
The forms in question, called Notice of Transfer/Discharge, are the only documents residents sign when they leave the facility. That detail came from the Director of Nursing herself, during an interview with inspectors on August 18. Neither resident's form carried a signature.
For Resident 1, a registered nurse named RN 1 had signed the form instead. The Director of Nursing told inspectors that RN 1 simply forgot to have the resident sign it. For Resident 2, the signature line was blank at the time of discharge.
The transfer notice is not a formality. It documents that a resident was told about their discharge location, their belongings, and their medications before they left. Without a resident's signature, there is no record that any of that information was actually communicated to the person being discharged.
RN 2, interviewed separately at 4:50 PM on the same day, explained how the facility interpreted a nurse's signature on the form. When RN 1 signed it, RN 2 said, that meant the resident had been notified of the details. The resident's own signature, RN 2 acknowledged, was what the form was supposed to carry.
The Director of Nursing, in a follow-up interview at 5:03 PM, confirmed that both forms were missing resident signatures and said the signatures were required for legal purposes and proper documentation. The facility's own policy on transfer and discharge, dated October 2022, states that when a resident leaves, the medical record must document that appropriate notice was provided to the resident or their legal representative. Its broader charting policy, last revised in July 2017, requires documentation to be objective, complete, and accurate.
Neither form met that standard.
Inspectors cited the facility under F0842, which covers the accuracy and completeness of resident records. The deficiency was tagged at a level of minimal harm or potential for actual harm, and the citation noted that some residents were affected.
What the inspection does not resolve is whether either resident actually knew, before leaving, where they were being sent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Gardens Healthcare from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
ROYAL GARDENS HEALTHCARE in ALHAMBRA, CA was cited for violations during a health inspection on August 21, 2025.
The forms in question, called Notice of Transfer/Discharge, are the only documents residents sign when they leave the facility.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.