Royal Senior Living

Allegation investigated: 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.

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 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.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 22-AS-20230106144959

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Feb 5, 2026

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: 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.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 11, 2026

(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: 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.the state’s words, verbatim · CDSS document, Feb 4, 2026

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Elma Parohinog. Administrator (AD) Ashkan Bastani was notified via telephone by staff. For today’s visit, LPA observed a total of six residents in care and two staff members on duty. LPA observed the Administrator's Certificate for facility AD Ashkan Bastani which expires on October 22, 2027. LPA Ramirez toured the interior and exterior portions of the facility with Caregiver Parohinog. The facility is a one-story home and is licensed for five non-ambulatory clients and one bedridden. The facility has a Hospice waiver for four. There are a total of five bedrooms of which four are for residents and one for staff. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. LPA observed all windows were screened. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of two restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 107.8-109.9 degrees Fahrenheit. Food menu was also posted and visible. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Fire extinguisher was observed to be fully charged and mounted by the kitchen. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. CONTINUED ON LIC809-C.. LPA Ramirez observed the emergency disaster and evacuation plan, which is located by hallway next to the kitchen. Facility had back-up emergency food and water supply. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care. For the exterior portion, LPA Ramirez observed a shaded area, patio furniture, and the grounds were free of any hazards. There are two gates in the backyard. No bodies of water were observed. LPA reviewed six of six resident files and four staff files. LPA interviewed six residents and two staff. During today's visit LPA observed clients' having chicken with vegetables and/or salad for lunch. For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with facility representative. A copy of this report was provided at the time of exit.the state’s words, verbatim · CDSS document, Dec 12, 2025

Allegation investigated: Staff is not criminal record cleared

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required 10-day visit to begin the investigation into the allegations listed above. LPA met with Administrator Ashkan Bastani and explained the reason for the visit. LPA toured the facility. LPA interviewed staff and residents. LPA reviewed facility records, staff records and the facility roster in Guardian background check system. The investigation into the allegation revealed the following. Facilty has 5 regular staff and 2 private caregivers who are employed by the families of Resident 1 and Resident 2. The 2 private caregivers (Staff 6 and Staff 7) both reported they do not work for an Agency and are employed directly by the families of the residents. Staff 1 and Staff 2 are background cleared and associated to the facility. The Administrator is associated to the facility. Staff 3, Staff 4 and Staff 5 are not associated to the facilty. Staff 3, Staff 4 and Staff 5 were not present at the facility during the visit. Staff 1, Staff 6 and Staff 7 were present at the facility when the LPA arrived. LPA observed both Staff 6 and Staff 7 leave the facility. Substantiated Based on the evidence gathered the allegation is deemed unsubstantiated. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted and a copy of the report provided. 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. Immediate civil penalties are being issued. An exit interview was conducted and a copy of the report along with appeal rights was provided.the state’s words, verbatim · CDSS document, Oct 31, 2025 · control 22-AS-20251030090606

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Nov 1, 2025

87355(e)(2) All individuals subject to a criminal record review...(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department… This requirement was not met evidenced by: Based on a record review Staff 6 does not have a California clearance or a as required by the Department. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: Licensee agrees to have all staff background cleared/trasnferred and associated to the facility before allowing any staff to work at the facility. Licensee agrees to sign a statement of understanding of CCR 87355 and to provide the signed statement by the POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Nov 1, 2025

87355 (e)(3) All individuals subject to a criminal record review... (b) shall prior to working, residing or volunteering in a licensed facility: (3)Request a transfer of a criminal record clearance... This requirement is not met as evidenced by: Based on a record review Staff 7 does not have a transfer of their criminal record clearance as required by the Department. This poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: Licensee agrees to have all staff background cleared/transferred and associated to the facility before allowing any staff to work at the facility. Licensee agrees to sign a statement of understanding of CCR 87355 and to provide the signed statement by the POC due date.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct a case management visit. LPA met with Administrator Ashkan Bastani and explained the reason for the visit. During the investigation of complaint # 22-AS-20251030090606 it was discovered that Resident 2 suffered a fall and was taken to the hospital to be treated. The facility Administrator notified the family of Resident 2 but did not report the incident to the Agency (Community Care Licensing). This is a violation of Title 22, California Code of Regulation (CCR) 87211 which states, "(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident." LPA consulted with Administrator concerning reporting requirements. 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 provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 31, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Nov 7, 2025

a) Each licensee shall furnish to the licensing agency such reports... (1)(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not being met as evidenced by, Resident 2 suffered a fall on October 15, 2025 which required the resident to be treated at the hospital and the facility did not report the incident to the Agency (Community Care Licensing). This poses a potential health, safety and personal rights risks to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2025

Plan of correction: Licensing agrees to report all incidents in compliance with CCR 87211 and to sign a statement of understanding stating they have read and understand CCR 87211. Licensee to submit proof to LPA by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Joseph Alejandre made an unannounced visit to conduct the required annual inspection. LPA met with Administrator Ashkan Bastani and explained the reason for the visit. The Administrator's certificate expires on October 22, 2025. Facility is licensed for a capacity of 6 non-ambulatory residents of which one can be bedridden and hospice waiver for 4. Facility is a singe story home with 5 bedrooms (1 is for staff), 2 bathrooms, kitchen, living room, dining room and a two car garage. The garage is kept locked and used for storage. Facility is operating within it's license. LPA observed the fireplace in the living room is screened. LPA observed the See Something Say Something Poster posted in the hallway next to the front door. LPA observed the kitchen is clean and organized. The 5 burner gas stove lights unassisted. LPA observed the cleaning supplies are kept locked under the kitchen sink and knives are kept locked in a kitchen drawer. The fire extinguisher in the kitchen is fully charged. Medication is kept locked in a cabinet in the hallway. LPA observed a clean linen supply in the hall closet. LPA observed all resident rooms had the required furnishings. LPA observed both bathrooms are clean and operational. Hot water measured 120.0 degrees Fahrenheit in both bathrooms. LPA observed Resident 1 (R1) had a bed rail on their bed but did not have a doctor's order for a bed rail. LPA observed the backyard had a table with chairs and an umbrella to sit outside. No bodies of water observed in the backyard. Both exit gates are operational. No obstacles or hazards observed in the backyard. LPA reviewed resident files and medications. LPA observed 5 out of the 6 resident files had no discrepancies. Resident 1 had a bed rail but no doctor's order for a bed rail. Smoke detectors/carbon monoxide detectors were tested. There is a smoke detector in each hallway on both sides of the house, both smoke detectors (2) in the hallways were not operational. All smoke detectors in the living room and in each bedroom are operational. During the visit the batteries were changed in the 2 smoke detectors in the hallways and both hallway smoke detectors are now operational. LPA reviewed 2 staff files, there was no documentation for any current training for both staff members. LPA observed Staff 1 had current CPR/First aid training. The last fire drill was conducted on November 10, 2024. The first aid kit has ll the required elements. Facility has a dedicated internet device for resident use. Deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. A civil penalty was issued on this date. An exit interview was conducted with the Administrator and a copy of the report along with appeal rights and LIC 421IM (civil penalty) was provided.the state’s words, verbatim · CDSS document, Dec 17, 2024

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.