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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110534
Report Date: 04/02/2025
Date Signed: 04/02/2025 11:29:26 AM

Document Has Been Signed on 04/02/2025 11:29 AM - 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 IIFACILITY NUMBER:
490110534
ADMINISTRATOR/
DIRECTOR:		GUEVARRA, ANTHONY DFACILITY TYPE:
735
ADDRESS:3467 PHILLIPS AVE.TELEPHONE:
(707) 573-4705
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 20CENSUS: 17DATE:
04/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Tony Guevarra (Licensee)TIME VISIT/
INSPECTION COMPLETED:
11:44 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual inspection and met with Licensee, Tony Guevarra and back up Administrator Janet Hermogenes. Annual fees are current. Contact information was reviewed. Required postings were observed

LPA/Licensee initiated a tour of the facility at 9:00am and made the following observations: Facility was a comfortable temperature. Residents rooms furnished per regulation including chair, night stand and dresser. Water temperature in client bathrooms measured at 109.9, 118 and 119.5 degrees F which are within allowable range of 105 to 120 degrees F. Toilet paper was observed in restrooms. Facility has at least two days of perishable and one week of non-perishable foods. Fruit basket with fruits was observed in the dining room accessible for clients. Cleaning supplies are stored under the sink in the locked kitchen. The kitchen is locked unless there is a staff member inside. Medications were centrally stored and locked in the medication cart located in the kitchen. One of the separate buildings houses the laundry room which was locked at time of inspection. Fire extinguishers were last inspected November, 2024. Smoke detectors are hardwired and inspected yearly by a vendor. Most recent service was conducted 11/11/24. Carbon monoxide detectors in each building were tested and operational. Most recent fire drill conducted on 1/27/25. Menus, internet accessibility and activity calendar were posted. The facility does have a subsequent annual bacteriological analysis of the water supply to ensure the safety of clients dated 2/24/25. Cash resources reviewed.

Continued on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 04/02/2025
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Continued from LIC809...

File review was initiated at 10:00 am. Three staff files and nine client files were reviewed. Two out of nine client's (C1) do not have a medical assessment on file (technical violation issued). All client's care plans have been updated as stated per regulation. First Aid and CPR certificates for staff were current. Administrator Certificate for Administrator, Anthony Guevarra. 6008632735 expires 5/19/2025. Medications and medication records were reviewed. Client's weight records are updated in a monthly basis, records reviewed.

Licensee provided updates of the following documents: Personnel Report (LIC500), Designation of facility responsibility (LIC308), Affidavit for Clients (LIC400), surety bond and Emergency Disaster Plan (LIC610E).

No deficiencies cited during today's inspection.

Exit interview conducted with Licensee and copy of this report given.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025
LIC809 (FAS) - (06/04)
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