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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490108263
Report Date: 04/04/2024
Date Signed: 04/04/2024 04:49:11 PM

Substantiated


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
01/10/2024 and conducted by Evaluator Dina Alviso
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240110145614

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: 15DATE:
04/04/2024
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH: Danilo Galicia, Lead CaregiverTIME COMPLETED:
02:00 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 sybsequent complaint inspection, on 4/4/2024 at approximately 9:35am, and met with Danilo Galicia, Lead Caregiver. Danilo contacted the Administrator Tony Guevarra and notified them of the LPA's arrival. Administrator Janet Hermogenes, Administrator Back-up, arrived to the facility to meet with the LPA.

The Department reviewed client records, including medical/hospital records. The Department reviewed facility records. The Department conducted interviews with staff, and other related parties regarding the allegation. Reporting Party (RP) alleges that there was "Severe neglect/lack of supervision". The Department's complaint investigation revealed, on 12/25/2023, C1 was transported to the hospital after a fall, which resulted in injury(s). Per medical records review, and interviews, C1 was diagnosed with having lice and scabies on 12/25/23 when brought into the hospital. Per review of medical records, and interviews, on 9/11/2020, C1 had crossed the street from the facility, and was hit by a vehicle.

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

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

DATE: 04/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20240110145614
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: 04/04/2024
NARRATIVE
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 C1 had a cataract(s) at the time they were trying to cross two lanes of traffic to get across the street. 911 was called by another driver who witnessed the client be hit by the vehicle. Per facility file reviews, there was no documentation regarding this incident and/or care plan regarding current needs of the client at the time of this incident or after incident.

The incident of C1 on 9/11/2020 was not reported per record reviews, and investigation; This deficiency will be cited on a case management report as it is not related to the complaint, see LIC809/809D, dated 4/4/2024.

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 "Severe neglect/lack of supervision" is substantiated. Due to the substantiation, a deficiency will be cited. 80078(a) Responsibility for Providing Care and Supervision The licensee shall provide care and supervision as necessary to meet the client's needs, 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 Licensee/Administrator Tony Guevarra.
Appeal Rights Provided to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

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

DATE: 04/04/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20240110145614
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2024
Section Cited
CCR
80078(a)
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80078(a) Responsibility for Providing Care and Supervision The licensee shall provide care and supervision as necessary to meet the client's needs. This requirement was not met as evidenced by: Department investigation revealed, per medical records, and interviews, C1 was diagnosed with having lice and scabies on 12/25/23 when brought into the hospital. Per review of medical records, and interviews, on 9/11/2020, C1 had crossed the street from the facility, and was hit by a vehicle.
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Facility Licensee to ensure that all clients current needs are able to met by the facility/facility staff at all times; Ensure all incidents, any reassessments, and updates to care plans are documented as needed/required.
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Per file reviews, there was no documentation regarding this incident and/or care plan regarding current needs of the client at the time of this incident or after the incident. This is a health & safety and/or personal rights risk to client(s) in care.
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Ensure current care plan meets client's needs. Submit plan of future compliance with this regulation no later than 4/5/2024.
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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: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

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

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