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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306003568
Report Date: 09/04/2025
Date Signed: 09/04/2025 05:20:29 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
03/01/2023 and conducted by Evaluator Hanna Gough
COMPLAINT CONTROL NUMBER: 22-AS-20230301135048
FACILITY NAME:ROYALE BEST CARE HOMEFACILITY NUMBER:
306003568
ADMINISTRATOR:LEILANI & NOLAN ALEJANDROFACILITY TYPE:
735
ADDRESS:12051 GILBERT STREETTELEPHONE:
(714) 530-8181
CITY:GARDEN GROVESTATE: CAZIP CODE:
92841
CAPACITY:6CENSUS: 3DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Leilani Alejandro TIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility P& I ledgers are not accurate for the clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hanna Gough arrived at the facility for the purpose of investigating the above mentioned allegation. LPA was greeted and granted entry by staff. LPA met with Administrator (AD) Leilani Alejandro and discussed the purpose of the visit.

The investigation into the allegation Facility P& I ledgers are not accurate for the clients revealed the following: During the course of the investigation records review revealed that Client #1 (C1) was placed at the facility on August 1, 2020 and has a physicians report dated April 15, 2022 stating that they are not able to manage cash resources. LPA reviewed C1s P&I ledger for December 2022 and observed that on December 12, 2022 a purchase of $9.23 was made for Costco socks. LPA did not observe a receipt in C1s ledger for this purchase. LPA and AD observed the P&I ledger for C1 for the year of 2022 and the facility was unable to provide all the receipts the ledger noted and had receipts for C1 that the facility did not note on the ledger.
Continue on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Hanna Gough
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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-20230301135048
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: ROYALE BEST CARE HOME
FACILITY NUMBER: 306003568
VISIT DATE: 09/04/2025
NARRATIVE
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Client #2 (C2) was placed at the facility on April 13, 2012 and has a physicians report dated November 13, 2023 stating that they can manage their own cash resources. C2 has an IPP dated May 15, 2023 stating that the facility will maintain receipts and P&I ledger of C2. The facility could not provide LPA documents dated before December 2022. LPA observed an email from No Ordinary Moments (NOM) specialist dated January 26, 2023, requesting for the facility to make corrections to the ledger due to a Costco receipt dated December 12, 2022 of $9.23 being used for C3. LPA observed the receipt in C2s ledger with the same time stamp, date, and receipt number as C3, but with C2s initials. LPA observed two ledgers for C2 one with erased marking's with the words Costco socks still legible and one with the original marking's for Costco socks for $9.23. LPA and AD observed the ledger for C2 for the year of 2022 and the facility was unable to provide all the receipts the ledger noted and had receipts for C2 that the facility did not note on the ledger.

Client #3 (C3) was placed at the facility on November 16, 2013 and has a physicians report dated April 21, 2022 stating that they are not able to manage cash resources. LPA observed an email to the facility from NOM specialist to make corrections to the ledger and resubmit due to the same Costco receipt being used as C2 for Costco socks for $9.23. LPA observed the receipt in C3s ledger with the same time stamp, date, and receipt number as C2, initialed by C3. LPA and AD observed the P&I ledger for C3 for the year of 2022 and the facility was unable to provide all receipts the ledger noted and had receipts for C3 that the facility did not note on the ledger.

During interviews with staff it was revealed that Staff #1(S1) received the emails and fixed the errors that were made to the ledgers and resubmitted them to the NOM specialist. S1 stated they corrected the ledger in the way that NOM sees that it needs to be corrected. Staff #2 (S2) revealed that they were not handling the P&I ledgers until after this incident with NOM took place. S2 observed the discrepancy in C2’s ledger with LPA, but could not explain due to taking over after the incident. During interviews with C2 it was revealed that they do not have issues obtaining their P&I money with facility staff.

Based on observation, interviews, record review and information 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 Leilani Alejandro and a copy of this report, LIC 9099-D and appeal rights were left at the facility.

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

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230301135048
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: ROYALE BEST CARE HOME
FACILITY NUMBER: 306003568
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/03/2025
Section Cited
CCR
80026(h)
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80026(h) Safeguards for Cash Resources...
(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care...
This requirement is not met as evidence by:
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Licensee stated they will send LPA proof of trainings and updated policy for P&I ledger. Licensee will send LPA proof of completed ledger to LPA for the month of September by POC due date.
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Based on record review the licensee did not maintain accurate records of cash resources for 3 of 3 clients in care.
This poses as a potential personal rights risk to persons 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: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3