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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108263
Report Date: 09/02/2021
Date Signed: 09/02/2021 03:06:45 PM

Document Has Been Signed on 09/02/2021 03:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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:
09/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gus Guevarra-Lead StaffTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Alviso arrived to conduct an 1 YR Required inspection and met with Gus Guevarra, Lead Staff. Administrator Janet Hermogenes also was at the facility. The inspection is focused on the Infection Control procedures and practices of this facility.

Mitigation plan was approved by the Department on 7/28/21. Fire clearance is approved for twenty (20) ambulatory residents.

There were 19 residents in care at the facility. All visitors, essential visitors, and staff are to be screened upon entry; Temperatures are taken, and screening questions are to be answered before being allowed to remain in the facility, all information is logged. Residents are screened daily, and observed for any changes, all information is logged. Staff Gus Guevarra, and Licensee Tony Guevarra, agreed that this is in the facility's mitigation plan and the facility will ensure compliance with the covid screening requirements.

Toxins are stored in locked cabinets. There was a sufficient supply of hygiene products, cleaners, and paper products for use as needed. Medications are stored locked making them inaccessible to residents in care. All postings were up and visible to all as required. Facility has a sufficient supply of personal protective equipment(PPE). All staff had masks on during the LPA's inspection. LPA observed some clients with masks on when touring the facility grounds.

No deficiencies/citations.
Exit interview conducted with the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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