490108263-8-26-2025-21-AS-BMOS-DPXQ5E-20260102105145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 490108263
Report Date: 08/26/2025
Date Signed: 08/26/2025 01:43:45 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
08/19/2025 and conducted by Evaluator Dina Alviso

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250819103151

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: 16	DATE:	08/26/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Agusto (Gus) Guevarra-Lead Caregiver		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Staff did not provide medications to the resident, and falsified medication records

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alviso conducted a complaint investigation visit, on 8/26/25 at approximately 9:45am, and met with House Manager, Augusto (Gus) Guevarra. Licensee/Administrator Tony Guevarra , Licensee/Administrator arrived to meet with the LPA.

Reporting party alleges that "staff did not provide medications to the resident, and falsified medication records". House manager Gus provided the LPA records of former client, C1, that were on-site. Gus contacted Janet Hemogenes, back-up Administrator, to bring the rest of C1's file that the Licensee had recently taken. Licensee is working on possible admission of C1 into their other licensed care home, and this is why they had C1 file documents.

LPA reviewed all C1 records obtained. LPA obtained copies of medication records from the facility for the year of 2025 up to June 7, 2025 to 7/6/2025, and a hand written MAR medication record by S1, for 7/12/2025 to 8/11/2025.
Continued on LIc9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

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-20250819103151

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/26/2025

NARRATIVE

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LPA spoke with Omnicare Pharmacy who stated to the LPA that C1's medications were filled for July 2025; These medications, and MARs records didn't go out at the beginning of the cycle due to C1 not being in care at the facility at the time. C1 was in the hospital, per Licensee. Omnicare stated they provided medications for C1 starting on the 10th of July, 2025. Omnicare Pharmacy provided the pharmacy medicaton records, to the Licensee by email, of C1's medications that were filled from 7/10/2025 to 8/9/2025. Licensee provided the emailed Omnicare Pharmacy records to the LPA.

Investigation revealed that review of facility medication records show that facility marked off the days C1 received medications. Per review, there are no times that C1 didn't receive medications, except when C1 was hospitalized during the year of 2025. Per Interview with Omnicare Pharmacy, refills have been provided to the facility for C1 for June 2025, July 2025, and currently for August 2025. Per interviews with staff medications are provided to C1 as ordered. The medication records did not have any information documented of C1 refusing any medications. S1 stated that all medications were provide to C1 as ordered. S1 stated that they filled out handwritten medication record for July 2025, documents in the MARs records, and is the staff that provides all medications to residents in care. S1 stated if they are off and/or out of town, Staff Janet Hemogenes assists with the medications being provided the the clients in care. S1 denied that any of the medication records are falsified by them/by staff.

The investigation revealed that there was differing information obtained from information provided to the Department regarding the allegations. There was no information obtained that supported the violations had occurred.

Based on LPAs observations, record reviews, interviews with staff, and information obtained from other related party(s) there is insufficient information to prove or disprove the allegation of "staff did not provide medications to the resident, and falsified medication records". Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

No deficiencies cited.
Exit interview conducted with Lead Staff, Agusto Guevarra.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC9099 (FAS) - (06/04)

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