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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108263
Report Date: 03/03/2022
Date Signed: 03/03/2022 12:57:29 PM

Document Has Been Signed on 03/03/2022 12:57 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
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:
03/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Gus GuevarraTIME COMPLETED:
01:30 PM
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Licensing Program Analyst Leibert arrived unannounced for the purpose of amending a citation issued on March 01, 2022. The amending is necessary due to LPA error which stated an incorrect regulation number. The amended document cites the correct regulation. No other issues noted.

Copy of both documents left at facility.
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE: DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/03/2022
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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