490108263-9-2-2021-21-AS-HDBI-C7JP3C-20211006105719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 490108263
Report Date: 09/02/2021
Date Signed: 09/02/2021 03:09:27 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/05/2021 and conducted by Evaluator Dina Alviso

COMPLAINT CONTROL NUMBER: 21-AS-20210405165323

FACILITY NAME:	LE ELEN MANOR, INC		FACILITY NUMBER:	490108263
ADMINISTRATOR:	GUEVARRA, ANTHONY		FACILITY TYPE:	735
ADDRESS:	5522 OLD REDWOOD HWY		TELEPHONE:	(707) 569-9478
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95403
CAPACITY:	20	CENSUS: 19	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Gus Guevarra-Lead Staff		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility did not meet resident's care needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint investigation regarding the above allegation. LPA met with lead caregiver Gus Guevarra, at 10:20am on 9/2/21. Licensee Tony Guevarra arrived to the facility and also met with the LPA.

This Department has investigated the complaint by reviewing and obtaining records, conducting interviews with staff, and other related parties. The Department has determined that R1 (Resident) was admitted as an emergency placement, and arrived to the facility on 4/1/21 without any medications or clothing of his own.Staff Gus stated that they made calls on 4/1 and requested R1's medications be sent for the resident that was dropped off at the facility; Staff stated this was what had been agreed to when the facility was asked to admit the client who was coming from a hospital discharge. Facility staff stated that staff made calls until finally Omnicare was going to fill the orders and deliver the medications the next morning, 9/2/21. The medications arrived for the resident on 9/2/21. Staff stated to the LPA that the resident was to have their clothing with them when brought to the facility but the resident came with only what they were wearing.
Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210405165323

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LE ELEN MANOR, INC	FACILITY NUMBER: 490108263
	VISIT DATE: 09/02/2021

NARRATIVE

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Staff contacted the case manager and asked for resident's clothing to be brought to the facility. Staff stated that while waiting on information on residents clothing to be delivered, the resident had a change of clothing lent to him by another resident.Staff didn't receive any clothing for the resident so 4/3/21 a staff went and bought some clothing items for R1. Licensee followed up regarding the resident's clothing issue, and on 4/7/21 Tsunami Enterprises sent a check to the Licensee for the client to obtain clothing. Licensee went and purchased the clothing that the client wanted, and needed. Licensee provided copies of receipts from the 4/3, and 4/7, showing proof of purchase of clothing items. The resident refused to take medications prescribed by the Doctor, and was sent to the crisis center for professional medical assessment 5/13, per Doctor's report and referral. The resident didn't return to the facility and was discharged from the facility on 5/14/21.

Per record reviews, interviews, and observations, the allegation of the facility did not meet resident's care needs, is unsubstantiated. There is differing information regarding the allegation from both parties. Per record review, the client arrived 4/1/21 with no clothing but what they were wearing, and no medications prescribed by the Physician. The facility staff made calls and had medications on-site by 4/2/21. Resident had clothing provided by another resident on 4/2/21, and had clothing the staff purchased for them on 4/3/21. On 4/7 staff received a check for the client to obtain more clothing, proof of clothing purchases were provided to the LPA. Staff stated that they feel that they have addressed the issues regarding the clothing and medication in a timely manner.

Although the allegation may be valid, this Department has determined that the facility did not violate regulations in attempting to care for R1, and that there is not a preponderance of evidence to prove the allegation did, or did not, occur. Therefore, the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

LIC9099 (FAS) - (06/04)

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