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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110534
Report Date: 08/23/2022
Date Signed: 08/23/2022 01:25:01 PM

Document Has Been Signed on 08/23/2022 01:25 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 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: 17DATE:
08/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:47 AM
MET WITH:Chris Guevarra (House Manager)TIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Cuadra conducted a case management visit to cite deficiencies discovered during a complaint investigation #21-AS-20220722161626 and met with House Manager Chris Guevarra.

LPA learned through records review and interviews on 7/26/22 with House Manager Chris Guevarra and Licensee Tony Guevarra that facility did not have available copies of dated menus served in facility file for LPA’s review. On 7/27/22 Licensee provided weekly menus, but they were not dated per regulation. During today’s visit, LPA/House Manager observed a weekly menu located on the facility refrigerator. LPA discussed with House Manager the importance of generating weekly menus a week in advance, dated and keep on facility file for at least 30 days.

LPA also followed up on a self-incident report submitted to CCL on 8/15/22. Per incident report, on 8/10/22 around 10:45pm client (C1) went out in the smoking area with another client (C2) when C1 was trying to go back in their room C2 was stretching their legs, C1 tripped and fell on the floor, C1 couldn’t get up and C2 called House Manager for help. House Manager called 911 after assessing C1 was transported to Santa Rosa Memorial Hospital where they were diagnosed with broken hips and was needing surgery. C1’s responsible parties were notified. During today’s visit, LPA conducted confidential interviews with staff and clients. Per House Manager, the facility was informed that C1 had surgery last week and was going to be relocated to North Bay Rehabilitation in Petaluma, Ca for about a month to get recover. Internal investigation conducted by facility and LPA follow up concluded that incident was an accident occurred between clients and the facility followed regulations.

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: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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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Document Has Been Signed on 08/23/2022 01:25 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/23/2022 at 12:06 PM
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
, 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: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
80076(a)(5)

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80076 Food Services (a) In facilities providing meals to clients, the following shall apply:(5) Menus shall be written at least 1 week in advance & copies of the menus as served shall be dated and kept on file for at least 30 days...available for review by the clients/authorized rep & licensing upon request. This requirement has not been met as evidence by:
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Licensee to submit plan on how they will stay in compliance and ensure that weekly dated menus are kept on facility file and available for review upon request as stated per regulation by POC due date.



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Based on LPA’s observations, records review and interviews conducted on 7/26/22, 8/15/22 and 8/23/22 with House Manager/Licensee that facility did not have copies on facility file of dated menus served for the last 30 days for LPA’s review as stated per regulation which poses a potential 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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2022


LIC809 (FAS) - (06/04)
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