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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490108263
Report Date: 10/10/2024
Date Signed: 10/10/2024 02:14:47 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
10/08/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241008105026
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: 19DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Augusto Guevarra-House Manager/LeadTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility staff are not addressing vermin in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint investigation visit, on 10/10/24 at approximately 10:00am, and met with House Manager, Augusto (Gus) Guevarra. Licensee/Administrator Tony Guevarra was not available. Janet Hemogenes, back-up Administrator arrived to meet with the LPA.

House manager Gus provided the LPA copies of the facility food menu posted up in the facility.
LPA inspected the food supply, including the food storage shed/room. The LPA reviewed client medication records. The LPA toured the facility with Administrator Janet, and House Manager Gus. The LPA inspected common areas of the facility, including some resident rooms. The facility has a large field behind it, and the facility has had field mice/rodent problems in the past. House Manager Gus stated they do have the issue sometimes of rodents but there are no traps set out at this time; House Manager stated they would set some up around the facility and wherever they are needed. The LPA conducted interviews with staff, and with other related parties regarding the allegations. The investigation revealed that the facility has a large field behind it, and per a previous citation in 2017, the facility is to have a maintenance plan in place regarding trying to help ensure to keep the field mice/rodents out of the facility. Per staff (S2) interview, there is no maintenance plan in place, no traps, and no facility pest control services coming into the facility.
Continued on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
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 4
Control Number 21-AS-20241008105026
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: 10/10/2024
NARRATIVE
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There is no plan being followed addressing "vermin in the facility", (keeping vermin out). Per LPA's interviews the facility has had a rodent problem. Staff 2 had told the LPA that currently there are no glue traps on the facility property, they used to have the traps out, but not right now. S2 stated they have had rodent problems in the past. There is sufficient information obtained from review of facility records, and interviews with staff, and other parties, that support a violation has occurred regarding the allegation.

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 "Facility staff are not addressing vermin in the facility" is substantiated. Due to the substantiation, a deficiency will be cited, 80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times, 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 the Administrator Janet Hemogenes.
Appeal Rights Provided to the Administrator.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
10/08/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241008105026

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: 19DATE:
10/10/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Augusto Guevarra-House Manager/LeadTIME COMPLETED:
02:20 PM
ALLEGATION(S):
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Facility staff are not providing good quantity and quality of food to residents in care
Facility staff are forcing residents to take medication
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alviso conducted a complaint investigation visit, on 10/10/24 at approximately 10:00am, and met with House Manager, Augusto (Gus) Guevarra. Janet Hemogenes, back-up Administrator arrived to meet with the LPA. House manager Gus provided the LPA copies of the facility food menu posted up in the facility. LPA inspected the food supply, including the food storage shed/room. The LPA reviewed client medication records. The LPA toured the facility with Administrator Janet and House Manager Gus. The LPA inspected common areas of the facility, including some resident rooms. Staff, S1 & S2, stated no client is forced to take medications; Staff stated they provide the prescribed medications to the client, and if a client refuses, we explain why they should take the medications.If a client continues to refuse, we log it down. The investigation revealed that the food supply is sufficent of perishable and nonperishable food items,and medications are provided per Dr's Orders to clients in care. Per review of records, Interviews conducted with staff,and other related parties, there was conflicting information regarding reported allegations of "facility staff are not providing good quantity and quality of food to residents in care & facility staff are forcing residents to take medication". There was no information obtained that supported violations had occurred.Based on interviews, record reviews, and related information obtained during the investigation, the allegations are Unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. No deficiencies cited.
Exit interview conducted with the Administrator Janet Hemoggenes. Appeal Rights Provided.
"Amended" This is an amended version of the original report created on 10/10/24.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

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

DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20241008105026
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: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
Section Cited
CCR
80087(a)
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80087(a) Buildings and Grounds. The facility shall be kept clean, sanitary and in good repair at all times. This requirement wasn't met as evidenced by: The investigation revealed that the facility has a large field behind it, and per a previous citation in 2017, the facility is to have a maintenance plan in place regarding trying to help ensure to keep the field mice/rodents out of the facility. Per staff (S2) interview, there is no maintenance plan in place, no traps, and no facility
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Licensee/Administrator to ensure that facility is free of rodents in the facility, including all sheds/storage, client rooms and closets, common areas, and bathrooms. Ensure that facility follows a maintenance plan to ensure the facility is free of rodents, obtaining professional pest/exterminator services/advice and developing a good maintenance plan.
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 pest control services coming into the facility. S2 stated they have had rodent problems in the past. S2 stated they will put out traps. This deficiency is a risk to resident's personal rights and a risk to health & safety of residents in care.
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Facility staff stated they will be putting out traps immediately, as of today 10/10/24. Licensee/Administrator to review the maintenance plan and include how facility will ensure to address the continued rodent problem at the facility. POC due 10/17/24.
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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: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4