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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490108263
Report Date: 02/02/2026
Date Signed: 02/02/2026 01:54:37 PM

Substantiated


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
01/27/2026 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20260127163559
FACILITY NAME:LE ELEN MANOR, INCFACILITY NUMBER:
490108263
ADMINISTRATOR:GUEVARRA, ANTHONYFACILITY TYPE:
735
ADDRESS:5522 OLD REDWOOD HWYTELEPHONE:
(707) 569-9478
CITY:SANTA ROSASTATE: ZIP CODE:
95403
CAPACITY:20CENSUS: DATE:
02/02/2026
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Agusto (Gus) Guevarra-House Manager/Lead CaregiverTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Licensee did not ensure that the facility is free from pests
INVESTIGATION FINDINGS:
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fleasnsing Program Analyst (LPA) Alviso conducted a complaint investigation visit, on 2/2/2026 at approximately 11:40pm, and met with House Manager/Lead Staff Augusto (Gus) Guevarra. Tony Guevarra, Licensee/Administrator arrived to meet with the LPA.

Reporting party alleges that "licensee did not ensure that the facility is free from pests." LPA reviewed resident (R1) records, conducted interviews with staff, and other related parties. While the LPA was reviewing a file that was stored in the facility kitchen, a roach crawled out of the file. Staff Agusto (Gus) threw the roach off the table and killed it. LPA obtained medical information that when the resident went out, R1 was diagnosed to have bugs/fleas on their clothes while being assessed by medical professionals.

The investigation revealed that per interviews, observations by the LPA, and medical information obtained on R1, the facility is not free from pests, There was sufficient information obtained to support a violation occurred regarding the allegation.
Continued on LIC9099C..
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2026
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 5
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
01/27/2026 and conducted by Evaluator Dina Alviso
COMPLAINT CONTROL NUMBER: 21-AS-20260127163559

FACILITY NAME:LE ELEN MANOR, INCFACILITY NUMBER:
490108263
ADMINISTRATOR:GUEVARRA, ANTHONYFACILITY TYPE:
735
ADDRESS:5522 OLD REDWOOD HWYTELEPHONE:
(707) 569-9478
CITY:SANTA ROSASTATE: ZIP CODE:
95403
CAPACITY:20CENSUS: DATE:
02/02/2026
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Agusto (Gus) Guevarra-House Manager/Lead CaregiverTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Licensee is not ensuring resident’s needs, including hygiene care, are being met
INVESTIGATION FINDINGS:
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fleasnsing Program Analyst (LPA) Alviso conducted a complaint investigation visit, on 2/2/2026 at approximately 11:40pm, and met with House Manager/Lead Staff Augusto (Gus) Guevarra. Licensee/Administrator arrived to meet with the LPA.

Reporting party alleges that "licensee is not ensuring resident’s needs, including hygiene care, are being met." LPA reviewed resident (R1) records, conducted interviews with staff, and other related parties. The investigation revealed that resident (R1) is no longer in care at the facility. R1 was discharged to the facility on 1/26/26, and went out 911 after having a fall within the hour of their discharge, on 1/26/26.

Per interviews, R1 has lived at the facility for approximately 17 years, and is now needing a higher level of care, per interviews. R1 is able to shower themselves, and provide own hygiene care. There was no information obtained to support that a violation occurred regarding the allegation.
Continued on LIC9099C,,,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260127163559
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: 02/02/2026
NARRATIVE
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During the inspection, LPA discussed personal rights of residents in care, and ensuring all resident needs are met by the facility staff, including helping to ensure residents' hygiene care. Administrator & Lead staff stated their understanding of the above.

Based on LPAs observations, record reviews, interviews with staff, and interviews with other related party(s) there is insufficient information to prove or disprove the allegation of "licensee is not ensuring resident’s needs, including hygiene care, are being met". Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are Unsubstantiated.

No deficiencies cited.
Exit interview conducted with Lead Staff/House Manager, Agusto Guevarra.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 21-AS-20260127163559
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: 02/02/2026
NARRATIVE
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Based on Department's interviews with staff, interviews with other related parties, review of records, and information obtained, the investigation has revealed that the allegation of "licensee did not ensure that the facility is free from pests" is substantiated.

Due to the substantiation, a deficiency will be cited, 80087 Buildings and Grounds(a)(1)- 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. The licensee shall take measures to keep the facility free of flies and other insects, see LIC9099D.

The preponderance of evidence standard has been met, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited.

Failure to correct deficiencies by due dates, may result in additional deficiency citations and/or civil penalties being assessed.

Exit interview conducted with Lead Staff, Agusto (Gus) Guevarra.
Appeal Rights Provided to Gus Guevarra for the Administrator Tony Guevarra. .
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260127163559
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2026
Section Cited
CCR
80087(a)(1)
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80087 Buildings and Grounds(a)(1)- 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.The fleasnsee shall take measures to keep the facility free of flies and other insects,This requirement wasn't met as evidenced by:
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licensee/Administrator to ensure that facility is free of roaches, fleas, and all other pests/insects, Ensure the facility kitchen, including all sheds/storage, client rooms and closets, common areas, and bathrooms, clothing, furnishings, and linens, are free of bugs.insects/ and pests.
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 The investigation revealed that per interviews, information obtained, and LPA observations, LPA obtained medical information diagnosing R1 had bugs/fleas on their clothes while being assessed by medical professionals at the hospital; LPA observed a large roach crawl out of the file they were reviewing. The file was stored in facility kitchen. This is a health & safety risk to residents' in care.
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 Ensure that facility follows a maintenance plan to ensure the facility is free of pests, and obtain a professional pest/exterminator service company to inspect, treat, and advise and a good maintenance plan to ensure the facility remains free of pests once they are rid of pests. Follow with inspection report and maintenance plan by 2/6/26. POC due 2/3/26.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5