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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490110534
Report Date: 10/25/2022
Date Signed: 10/25/2022 09:43:21 AM

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
09/21/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220921150833
FACILITY NAME:LE ELEN MANOR IIFACILITY NUMBER:
490110534
ADMINISTRATOR:GUEVARRA, ANTHONY DFACILITY TYPE:
735
ADDRESS:3467 PHILLIPS AVE.TELEPHONE:
(707) 573-4705
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:20CENSUS: 18DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Chris Guevarra (House Manager)TIME COMPLETED:
09:58 AM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with house manager Chris Guevarra.

The Department received a SOC341 notifying CCL about an alleged violation of personal rights. Per SOC341, staff (S1) regularly shout and verbally abuse clients in care, shaming, degrading them and witnessed others in the home being slapped by S1. Based on interviews conducted during the investigation revealed that there have been instances where staff (S1) gets frustrated and yells at clients sometimes resulting in name calling. On 10/20/22, during a visit to the facility, S1 admitted raising their voice at clients in care when they don’t throw their cigarette butts in the proper trash can but denied having slapped clients in care. LPA conducted confidential interviews with 5 out of 18 residents in care which revealed no additional evidence to support S1 slapped clients in care. The preponderance of evidence standard has been met; therefore, the above allegation of personal rights is substantiated. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
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 3
Control Number 21-AS-20220921150833
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 II
FACILITY NUMBER: 490110534
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2022
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (1) To be accorded dignity in his/her personal relationships with staff and other persons. This requirement has not been met as evidence by:

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Administrator agrees to review Regulation 80072 with staff and submit self-certification that it has been completed, and personal rights of clients outlined by regulation will never be violated by POC due date. Regional office will be conducting an Informal Meeting with Licensee time and date to be determined.
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Based on interviews, the facility staff (S1) admitted that they have raised their voice and yelled at clients in care which poses an immediate risk to the health and safety of clients in care.
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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: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
09/21/2022 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20220921150833

FACILITY NAME:LE ELEN MANOR IIFACILITY NUMBER:
490110534
ADMINISTRATOR:GUEVARRA, ANTHONY DFACILITY TYPE:
735
ADDRESS:3467 PHILLIPS AVE.TELEPHONE:
(707) 573-4705
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:20CENSUS: DATE:
10/25/2022
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Chris Guevarra (House Manager)TIME COMPLETED:
09:58 AM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with house manager Chris Guevarra.

It was alleged that facility is in disrepair due to being reported several times that the conditions in the home are unsafe with reference made to the ceiling of resident’s bedroom. During the investigation, LPA spoke with House Manager and made observations. On 10/4/22 after LPA Hansen opened the complaint investigation, Licensee submitted two emails including pictures of minor facility repairs that were being performed by house manager that included walkway lose flooring and nails located in the second building of the facility. On 10/20/22 LPA/House Manager conducted a walk through the facility including resident’s bedroom referenced in the allegation and did not observed any damage to the ceiling. Also, the repairs to the walkway were already finished. A finding that the complaint allegation facility is in disrepair 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3