490108263-9-8-2025-21-AS-DALO-DLC298-20250908171130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490108263
Report Date: 09/08/2025
Date Signed: 09/08/2025 05:11:40 PM

Document Has Been Signed on 09/08/2025 05:11 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, INC		FACILITY NUMBER:	490108263
ADMINISTRATOR/ DIRECTOR:	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: 15	DATE:	09/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:50 PM
MET WITH:	Agusto (Gus) Guevarra-Lead Caregiver		TIME VISIT/ INSPECTION COMPLETED:	05:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Alviso arrived to conduct a Required- 1 Year inspection, at approximately 1:50pm 9/8/2025, and met with Lead Caregiver Gus Guevarra. There are two other caregivers on duty with Gus. Administrator J Tony Guevarra, arrived to the facility to meet with the LPA. Facility is fire cleared for twenty (20) ambulatory residents. Currently there are fifteen (15) clients in care at this time. LPA reviewed six (6) client files. All files were complete. LPA reviewed medication records, and medication storage during the inspection. LPA reviewed four (4) staff files. All staff have required criminal record clearance. All staff have first aid and CPR. LPA reviewed staff training. The LPA toured the facility with the Administrator Tony Guevarra. The LPA observed a sufficient supply of food. The resident bathrooms were clean and orderly. Residents had clean linens available for their use. Resident common area had seating for resident use, a working telephone, and cable television for resident use. There was an outside covered area where residents can sit outside in if wanting to and/or smoke if wanting to. Fire extinguishers were serviced and tagged, expires 11/4/25. All exits were free and c;ear of obstruction. Dining area was clean and orderly. Medications were centrally stored in a locked medication rolling cart. All resident rooms were clean and orderly during the inspection. Disinfectants/cleaners were locked up and inaccessible to residents in care. LPA observed laundry being done by staff during the inspection. Continued on LIC809C..

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 09/08/2025

NARRATIVE

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Please submit the following updated forms by 10/8/25:
LIC500-Personnel Report
LIC400-Client Cash Resources-including surety bond
LIC308-Designation of facility responsibility
Infection Control Plan- if any changes submit copy.
Client Roster
Copy of current Administrator certificate
Emergency Disaster Plan, 9 page document- if any changes submit copy.
Liability Insurance

Deficiency Observed:

Based on LPA's observation, a resident room, joint room, had a leak in the ceiling, there is water damage and the ceiling has a been opened up where the leak was. The roof is covered with a tarp at this time. The room is vacant, and smells of water damage. Room is kept locked at all times. Administrator stated that the resident room is getting the roof and ceiling fixed, and will be fully repaired before residents will be able to be placed in the room. This deficiency will be cited, Building and Grounds 80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors, see LIC809D.

The following deficiency 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, Tony Guevarra.
Appeal rights were provided to the Administrator with the facility evaluation report.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Dina Alviso
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/08/2025 05:11 PM - It Cannot Be Edited

Created By: Dina Alviso On 09/08/2025 at 04:56 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: 09/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, a resident room, joint room, had a leak in the ceiling, there is water damage and the ceiling has a been opened up where the leak was. The roof is covered with a tarp at this time. The room is vacant, and smells of water damage. Room is kept locked at all times. Administrator stated that the resident room is getting the roof and ceiling fixed, and will be fully repaired before residents will be able to be placed in the room, 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: 09/24/2025
	Plan of Correction
1 2 3 4	Licensee to ensure the resident room's ceiling and roof are repaired as needed. Submit plan of correction and time work will start, and be completed, for the resident room. Per discussion with Administrator, room's ceiling and roof will be repaired and completed by 11/10/2025. Licensee will send photos in of the repaired ceiling and roof of the resident room. Plan of correction/POC due 9/24/25.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Dina Alviso
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025

LIC809 (FAS) - (06/04)

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