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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490110534
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:33:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/23/2021 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210723081147
FACILITY NAME:LE ELEN MANOR IIFACILITY NUMBER:
490110534
ADMINISTRATOR:GUEVARRA, AUGUSTO D.FACILITY TYPE:
735
ADDRESS:3467 PHILLIPS AVE.TELEPHONE:
(707) 573-4705
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:20CENSUS: 20DATE:
08/26/2021
UNANNOUNCEDTIME BEGAN:
10:16 AM
MET WITH:Tony Guevarra (Licensee)TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff failed to seek timely medical for resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility met with Licensee, Tony Guevarra to deliver findings regarding the complaint allegations above. LPA conducted risk assessment call with Licensee, Tony Guevarra prior to the visit.

During investigation LPA reviewed records, conducted interviews and made observations at the facility. It was alleged that Staff failed to seek timely medical for resident in care. On 7/23/21 CCL was notified by reporting party that a client (C1) from this facility was diagnosed with scabies at Santa Rosa Memorial Hospital, C1 was examined for medical clearance due to moving out that day from the facility. LPA obtained C1’s discharge records dated 7/20/21 from Hospital confirmed C1 was diagnosed with “Scabies and had multiple stage rash to chest, upper arms and it was itchy for a week”. On 7/26/21 CCL received a self-incident report indicating that “on 6/21/21 facility issued a 30-day eviction notice to C1 and needed to vacate the premises by 7/21/21. Per Licensee, C1 was removed from the facility a day before the eviction due date of 7/21/21 by C1’s case worker.
Continues on LIC9099C…
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
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 2
Control Number 21-AS-20210723081147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 490110534
VISIT DATE: 08/26/2021
NARRATIVE
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Continued from LIC9099...

Administrator was later contacted and informed that C1 was diagnosed with scabies which Licensee stated that it was a false accusation and they were never informed that C1 experienced any itching. LPA conducted 10-day complaint inspection on 7/29/21, conducted interviews with Licensee, Administrator and clients (C2, C3 and C4) which appears to be healthy and no concerns were raised. LPA also conducted confidential interviews with C1 who informed LPA that they never reported the itching to any staff. Based on records review, C1 AWOL on 5/1/21 (case#210430020) and was given 3 eviction notices”. However, LPA reviewed incident report logs for this facility, and it was determined that eviction notices were not submitted to CCL. LPA will address eviction procedures on a case management. Based on records review and interviews conducted staff did not fail to seek timely medical for resident in care due to C1 did not alert staff that they were experiencing itching while residing in this facility.

A finding that the complaint allegation “Staff failed to seek timely medical for resident” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2