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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490108263
Report Date: 03/01/2022
Date Signed: 03/01/2022 12:22:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/18/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220118120334
FACILITY NAME:LE ELEN MANOR, INCFACILITY NUMBER:
490108263
ADMINISTRATOR:GUEVARRA, ANTHONYFACILITY TYPE:
735
ADDRESS:5522 OLD REDWOOD HWYTELEPHONE:
(707) 569-9478
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY:20CENSUS: 19DATE:
03/01/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Gus GuevarraTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident in care has lice and scabies
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with Gus Guevarra and discussed the findings. C1 was sent out for medical treatment on January 18, 2022 when client experienced difficulty breathing. While hospitalized a report was received that client had lice and scabies. This Department has investigated the allegation by making site visits, conducting interviews and reviewing documents. The following determinations are made: Facility staff deny observing lice on C1 and state Client's bedroom was swept and found to be free of lice; C1 has made contradictory statements regarding having lice/scabies; A licensed professional has stated to have observed C1 infested with lice which appeared to be in various stages of development; medical report obtained from the medical facility lists Lice as one of the medical diagnosis. Based upon the statements and records, the preponderance of evidence standard has been met. Therefore, the allegation is deemed to be SUBSTANTIATED.
The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
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 2
Control Number 21-AS-20220118120334
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LE ELEN MANOR, INC
FACILITY NUMBER: 490108263
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/08/2022
Section Cited
CCR
80075(a)
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HEALTH RELATED SERVICES. The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. ***Based upon documents and statements, this requirement not met as evidenced by:
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Administration will submit a written plan that outlines how the facility will comply with 80075 going forward. Plan to be submitted to CCL for approval by POC date in order to clear the deficiency.
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C1 was admitted to a medical facility on 1/18/2022 and observed to be covered with lice. This posed an immediate risk to C1's health.
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****This is an amended version of the original document.*****
Type B
03/08/2022
Section Cited
CCR
85075.4(a)
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OBSERVATION OF CLIENT. The licensee shall regularly observe each client for changes in physical, mental, emotional and social functioning. ***This requirement not met as evidenced by: C1 was admitted to a medical facility on 1/18/2022 and observed with lice. Facility staff state they were not aware of C1's condition.
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Administration will submit a written plan that outlines how the facility will comply with 85075.4 going forward. Plan to be submitted to CCL for approval by POC date in order to clear the deficiency.
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This posed a potential risk to C1's health.
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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: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2