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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003567
Report Date: 10/15/2025
Date Signed: 10/15/2025 02:57:17 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
05/19/2023 and conducted by Evaluator Hanna Gough
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20230519101250
FACILITY NAME:STATE ROYALE GUEST HOMEFACILITY NUMBER:
306003567
ADMINISTRATOR:LEILANI ALEJANDROFACILITY TYPE:
735
ADDRESS:840 STATE COLLEGE BLVD., S.TELEPHONE:
(714) 563-2392
CITY:ANAHEIMSTATE: CAZIP CODE:
92806
CAPACITY:6CENSUS: 4DATE:
10/15/2025
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Antoinette NicholsTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Unlawful eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned complaint allegation. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Antoinette Nichols and discussed the purpose of the visit.

The investigation into the allegation of an unlawful eviction revealed the following: It is alleged that the facility did not answer hospital staff phone calls for Client 1 (C1) to be discharged back to the facility in which they were currently living. Upon document request LPA observed an IPP dated February 24, 2021, stating that C1 has been living at the facility since July of 2000. LPA observed an incomplete IPP dated February 24, 2022, stating that C1 needed continued placement at the facility. LPA did not observe an updated IPP for the year of 2023 or a needs and services plan. LPA observed a Special Incident Report dated March 28, 2023, signed by the facility AD stating that C2 was taken to the emergency room on March 27, 2023, due to a cough and shortness of breath. Continue on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
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 3
Control Number 22-AS-20230519101250
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: STATE ROYALE GUEST HOME
FACILITY NUMBER: 306003567
VISIT DATE: 10/15/2025
NARRATIVE
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The Special Incident Report states that the facility AD mentioned to C1s physician, that whatever the plans for C1 are, they can not take C1 back to the facility due to C1 needing a higher level of care that specializes with their health condition. Upon interviews with staff 1 (S1) it was revealed that C1 was taken to the hospital and was then transferred to a skilled nursing facility but, did not return to the facility. S1 informed LPA that they did not give an eviction notice due to C1 being admitted to the hospital and transferred to a skilled nursing facility. S1 denied receiving calls from hospital staff, but informed LPA that C1 needed to stay at the hospital for treatment due to their diagnosis.
LPA was unable to contact C1s responsible party.

Based on interviews and record review gathered during the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22 Division 6 are being cited on the attached LIC 9099D.

An exit interview was conducted with AD Antoinette Nichols and a copy of this report, LIC9099-D and appeal rights were left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230519101250
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: STATE ROYALE GUEST HOME
FACILITY NUMBER: 306003567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2025
Section Cited
CCR
80068.5(4)(A)
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80068.5 Eviction Procedures(4)(A)
(A) A Needs and Services Plan modification must have been performed... which determined that the client's needs cannot be met by the facility and the client has been given the opportunity to relocate...
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Administrator stated they will submit a new policy and procedure regarding eviction procedures as well as a statement of understanding of the entire regulation of 80068.5 and submit proof to LPA by POC due date.
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This requirement was not met as evidence by:
Administrator did not perform a needs and services plan to determine the client's needs which poses a potential health, safety or personal rights risk to clients 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: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3