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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108263
Report Date: 10/24/2024
Date Signed: 10/24/2024 03:19:47 PM

Document Has Been Signed on 10/24/2024 03:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:LE ELEN MANOR, INCFACILITY NUMBER:
490108263
ADMINISTRATOR/
DIRECTOR:		GUEVARRA, ANTHONYFACILITY TYPE:
735
ADDRESS:5522 OLD REDWOOD HWYTELEPHONE:
(707) 569-9478
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 20CENSUS: 19DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:22 PM
MET WITH:Agusto (Gus) Guevarra-Lead CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alviso arrived to conduct a Required- 1 Year inspection, at approximately 12:22pm on 10/24/24, and met with Lead Caregiver Gus Guevarra. There are two other caregivers on duty with Gus. Administrator Janet Hemogenes arrived to the facility to meet with the LPA as Licensee was not available. Tony Guevarra/Licensee has a current Administrator certificate, expires 5/19/2025, he is the primary Administrator.

Currently there are nineteen (19) clients in care at this time. LPA reviewed five (5) client files. All files were complete. LPA reviewed medication records, and medications.

LPA reviewed five (5) staff files. All staff have required criminal record clearance. All staff have first aid and CPR.

LPAs toured the facility with Administrator Janet, and Lead caregiver Gus. Food supply was sufficient. Fire extinguishers, nine (9), were found to be appropriately charged. Residents' common area/TV room was found to be clean and orderly. Cable was working appropriately, and the phone was available and working. Bathrooms were found to clean during the inspection.

LPA discussed with staff to ensure towels and linens are washed and cleaned as needed so clients don't have dirty towels, clothes, and/or sheets. Staff stated their understanding regarding the above. disinfectants/cleaners were locked up and inaccessible to clients. Medications were locked up and inaccessible to clients. Staff stated they will be painting areas throughout the facility as needed, this was discussed during the tour.

Please submit the following required annual updated forms by 11/24/24:
Review Emergency Disaster Plan,LIC610D, if any changes needed, update & submit. If no changes sign and date the review page and submit a copy.

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2024 03:19 PM - It Cannot Be Edited


Created By: Dina Alviso On 10/24/2024 at 02:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Per review of records and interview with staff, the facility hasn't held the disaster drills quarterly as required, and couldn't provide a record of any fire/disaster drills conducted at the facility by staff, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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Licensee/Administrator to ensure the facility conducts emergency disaster drills as required by HSC 1565(c). The facility to conduct a disaster/fire drill with all staff, and with any clients that want to be included in the drill, this must be done on each facility shift. Document the disaster/fire drill with all appropriate information, and submit a copy as part of your plan of correction, along with a schedule of the required quarterly drills. POC due 10/31/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: LE ELEN MANOR, INC
FACILITY NUMBER: 490108263
VISIT DATE: 10/24/2024
NARRATIVE
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Review the Infection Control Plan, LIC9283, if any changes needed, update & submit. If no changes sign and date the review page and submit a copy.
Copy of current Administrator certificate
LIC500-Updated personnel report
LIC400-Client Cash Resources-including surety bond
LIC308-Designation of facility responsibility

Per review of records and interview with staff, the facility hasn't held the disaster drills quarterly as required, and couldn't provide a record of any fire/disaster drills conducted at the facility by staff. This deficiency will be cited, HSC 1565(c)-A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. One of the drills needs to be an evacuation drill, see LIC809D

The following deficiencies is 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 with the Administrator, Janet Hemogenes.
Appeal rights were provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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