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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306006089
Report Date: 02/04/2026
Date Signed: 02/04/2026 03:15:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/06/2023 and conducted by Evaluator Joseph Alejandre
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230106144959
FACILITY NAME:ROYAL SENIOR LIVINGFACILITY NUMBER:
306006089
ADMINISTRATOR:BASTANI, ASHKANFACILITY TYPE:
740
ADDRESS:31742 ISLE ROYAL DR.TELEPHONE:
(949) 302-3696
CITY:LAGUNA NIGUELSTATE: CAZIP CODE:
92677
CAPACITY:6CENSUS: 6DATE:
02/04/2026
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Queeny SaboboTIME COMPLETED:
03:17 PM
ALLEGATION(S):
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Resident is left in a soiled diaper for an extended period sustaining lesions.
Resident did not receive medical care in a timely manner sustaining in unstageable wounds.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to deliver the findings of the complaint investigation into the allegations listed above. LPA met with staff member Queeny Sabobo and explained the reason for the visit. The investigation into the allegation, Resident did not receive medical care in a timely manner sustaining in unstageable wounds, revealed the following. Resident 1 (R1) moved into the facility on January 7, 2017. No issues or concerns were reported for R1 until November 19, 2022. According to R1’s physician's report dated October 14, 2022, R1 was diagnosed with Alzheimer’s disease, chronic atrial fibrillation and hypertension. R1's physician's report did not list any pressure injuries or skin issues. Staff reported that on November 18, 2022, R1 was noted to have a possible pressure injury on their heel. A medical assessment was ordered on November 18, 2022. On November 19, 2022, R1 had a home health assessment and was diagnosed with a stage 3 pressure injury on their left heel. 3 out of 3 staff interviewed could not explain how R1 developed a stage 3 pressure injury on their heel from October 14, 2022, to November 19, 2022.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 22-AS-20230106144959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROYAL SENIOR LIVING
FACILITY NUMBER: 306006089
VISIT DATE: 02/04/2026
NARRATIVE
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There are no facility records or home health records for the time period from October 14 to November 17, 2022. It is unclear how R1 developed a stage 3 pressure injury in that time but staff should have been aware of the injury before it developed to a stage 3 injury which required wound care. Home health was ordered for R1 and wound care provided to R1 beginning November 19, 2022. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated.

The investigation into the allegation, Resident is left in a soiled diaper for an extended period sustaining lesions, revealed the following. It was reported that Resident 1 (R1) sustained a pressure injury on their buttock. R1’s physician report dated October 14, 2022, did not have any mention of pressure injuries or skin issues. A review of hospice records shows that R1 was diagnosed with a stage 3 pressure injury on their left heel on November 19, 2022. R1 was diagnosed with stage 2 pressure injury on their coccyx on December 17, 2022. 1 out of 3 staff interviewed reported that R1 was regularly put in 2 briefs because they couldn’t always be changed quickly. Staff 1 reported that this practice was stopped because hospice requested them to stop. R1 was not always changed timely and developed a new pressure injury around a month after their first pressure injury was diagnosed. Based on the evidence gathered the preponderance of evidence standard has been met therefore the allegation is substantiated.

Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted and a copy of the report along with appeal rights was provided.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20230106144959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL SENIOR LIVING
FACILITY NUMBER: 306006089
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2026
Section Cited
CCR
87465(a)(1)
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Incidental medical and dental care 87465(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement was not met as evidence by:
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Licensee agrees to train staff on CCR 87465 and to submit proof of training to LPA. Licensee agrees to sign a statement of understanding, stating that they have read and understand CCR 87465.
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R1 was diagnosed with a stage 3 pressure injury on November 19, 2022. Staff did not notice or seek assistance until the injury was stage 3. This poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20230106144959
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROYAL SENIOR LIVING
FACILITY NUMBER: 306006089
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/11/2026
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidence by:
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Licensee agrees to train staff on CCR 87464 and to submit proof of training to LPA. Licensee agrees to sign a statement of understanding, stating that they have read and understand CCR 87465.
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R1 was not changed timely which resulted in R1 sustaining a stage 2 pressure injury on their coccyx. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Joseph Alejandre
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4