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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490108263
Report Date: 09/27/2022
Date Signed: 10/26/2022 01:23:19 PM

Document Has Been Signed on 10/26/2022 01:23 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:
7075699478
CITY:SANTA ROSASTATE: CAZIP CODE:
95403
CAPACITY: 20CENSUS: 20DATE:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dan Galicia-CaregiverTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Alviso arrived to conduct a Required- 1 Year inspection and met with Dan Galicia, caregiver. Janet Hermogenes, Administrator of another home owned by the Licensee, arrived at the facility to meet with the LPA. The inspection is focused on the Infection Control practices and procedures of this facility. Currently there are twenty(20) clients in care at this time.

Facility has submitted the Infection Control Plan as required. LPA toured the facility. The fire extinguishers are current, serviced and tagged, expires 10/20/22. Administrator Janet H. stated that all eight(8) fire extinguishers will be serviced and tagged before expiration date. All exits were cleared from obstruction. The common area was found to be orderly and have a working telephone and cable tv for resident use. Food supply was sufficient. Medications were locked up and inaccessible to clients. Cleaners were locked and inaccessible to clients in care.

**PLEASE SEE LIC812 WITH THE FACILITY EVALUATION REPORT -REQUIRED 1-YEAR INSPECTION COMPLETED 9/27/22, SIGNED BY LPA, ADMINISTRATOR, AND ON-FILE. COPY LEFT WITH ADMINISTRATOR JH, AND ON-FILE WITH CCL.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
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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