<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110534
Report Date: 08/26/2021
Date Signed: 08/26/2021 11:31:27 AM

Document Has Been Signed on 08/26/2021 11:31 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Tony Guevarra (Licensee)TIME COMPLETED:
11:45 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Cuadra conducted a case management visit to cite deficiencies discovered during a complaint investigation and met with Licensee, Tony Guevarra. LPA conducted risk assessment call with Licensee, Tony Guevarra prior to the visit.

LPA learned through interviews on 7/29/21 with Licensee and Administrator had failed to submit Eviction Notices issued to Client (C1) to CCL within 5 days of occurrence as stated per regulation (85068.5 Eviction Procedures)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 08/26/2021 11:31 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/26/2021 at 10:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: LE ELEN MANOR II
FACILITY NUMBER: 490110534

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2021
Section Cited
CCR
85068

1
2
3
4
5
6
7
Type B - 85068.5 Eviction Procedures (e) A written report of any eviction processed in accordance with (a) above shall be sent to the licensing agency within five days of the eviction. This requirement was not met based on evidence by:
1
2
3
4
5
6
7
Licensee/Administrator to ensure all incidents that threaten the safety of clients are reported to CCL per regulation. Licensee/Administrator to review regulation, conduct staff training for all staff on eviction procedures. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date 9/16/21.
8
9
10
11
12
13
14
Based on LPA's interviews and records review submitted to CCL, Licensee did not ensure that CCL was notified of C1’s eviction notices issued which poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2