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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490108263
Report Date: 04/24/2024
Date Signed: 04/24/2024 01:35:04 PM

Unsubstantiated


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
01/17/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240117112719
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: 16DATE:
04/24/2024
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Danilo Galicia-Lead Caregiver TIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Severe neglect/lack of supervision
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint investigation visit, on 4/24/24 at approximately 9:20am, and met with lead caregiver, Danilo Galicia. Licensee/Administrator Tony Guevarra arrived to meet with the LPA; Janet Hemogenes, back-up Administrator arrived after the Licensee.

LPA reviewed client records on C1, and obtained copies. The reporting party (RP) alleges severe neglect/lack of supervision of client (C1) by facility staff. C1 was transported to the hospital by 911 after a fall at the facility; C1 was covered with dried feces and their pants were soaked in urine. C1 had bruising on their body, including on their chest, in various stages of healing. R1 was medically assessed and found to have pneumonia, and it was documented that the bruising appeared to not be from a physical assualt but possibly multiple falls. The Department reviewed records and conducted interviews regarding the allegation of “severe neglect/lack of supervision" of client C1. The LPA reviewed records, and conducted interviews with staff, and other related parties regarding the allegation. The investigation revealed that C1 was a resident of the facility for approximately 30 years, C1 would often avoid hygiene care, showering, and changing of their clothing.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
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-20240117112719
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
VISIT DATE: 04/24/2024
NARRATIVE
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Per record reviews and interviews, C1 has a Case Manager (CM) with the County, who is in contact with the facility and the client regularly, and as needed. Per interviews with staff, S2, S3,and S4, the client (C1) would not want to shower and get cleaned up and/or change their clothes as needed, but staff would continue to ask C1 to shower, and sometimes they could get the client to, and other times it wouldn't be until the next day. Staff S3 stated they would tell the client they needed to shower so they can be clean because C1 was having a bad odor. S3 stated we staff tell C1 and they wouldn't want to shower, and go back later and ask again, and C1 will shower. S3 stated this is what we had to do. S4 stated that they saw C1 on the flloor on 1/13/24, and called S2 to help them get client (C1) up. S4 stated they helped C1 shower because they had urine and feces on their pants area, clients pants had fallen down when they fell. S2 assessed the need to call 911 for C1 to be medically assessed due to the client not responding well to S2's questions. Staff stated they had not observed the client C1 to have falls, and staff stated that C1 walked slow but did ambulate on their own. Staff stated they have not seen the client bruised all over; S1 stated that C1 smokes constantly, and always coughs on the cigarette smoke. S1 stated that if C1 had any falls they were not observed, and staff were not told or aware of it. S1 stated that they call 911 as needed, and responsible party, including the Doctor. S1 stated that they had told the case manager (CM) that the facility is for ambulatory only, and the client should be placed in higher level of care if health care needs have changed since the fall of 1/13/24. S1 stated the CM made the decision to place the client in a facility with a higher level of care. Per interviews with other related parties, C1 didn't like to shower or change clothes. Staff would remind C1 about getting showered. C1 could walk around on their own, they were just slow at it. There was no information obtained during the investigation to support a violation had occurred regarding the allegation.

Based on the interviews, record reviews, and related information obtained during the investigation, the allegation of “severe neglect/lack of supervision" of the client C, is Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

No deficiencies cited.
Exit interview was conducted with the Lead Caregiver Danilo Galicia.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2