490110534-4-1-2026-21-AS-MCUA-DSQSYF-20260401141729

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 490110534
Report Date: 04/01/2026
Date Signed: 04/01/2026 02:17:59 PM

Document Has Been Signed on 04/01/2026 02:17 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 II		FACILITY NUMBER:	490110534
ADMINISTRATOR/ DIRECTOR:	GUEVARRA, ANTHONY D		FACILITY TYPE:	735
ADDRESS:	3467 PHILLIPS AVE.		TELEPHONE:	(707) 573-4705
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY: 20		CENSUS: 18	DATE:	04/01/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:37 AM
MET WITH:	Tony Guevarra (Licensee)		TIME VISIT/ INSPECTION COMPLETED:	02:37 PM

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 arrived unannounced to conduct an Annual inspection and met with Licensee, Tony Guevarra & back up Administrator Janet Hermogenes. Annual fees current. LPA/staff initiated a tour of the facility 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 118.3, 118.7, 115.4 and and 102 degrees F which are within allowable range of 105 to 120 degrees F. Toilet paper was observed in restrooms, but there was no paper towels observed. LPA/back up administrator observed that washcloths were hanging on the bathroom towel bars for resident use in three resident bathrooms that are shared. LPA observed that the bathrooms didn’t have paper towels for resident use to help ensure sanitary hygiene care for all residents. LPA have a conversation with Licensee about the use of common wash cloths and towels shall be prohibited (technical violation issued). Facility has at least two days of perishable and one week of non-perishable foods. Fruit basket with fruits and cookies were 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. The facility does have a subsequent annual bacteriological analysis of the water supply to ensure the safety of clients dated October, 2025. Fire extinguishers were last inspected October, 2025. Smoke detectors are hardwired and inspected by a vendor (1/11/26). Continued on LIC809C...

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

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: 04/01/2026

NARRATIVE

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Continued from LIC809...Carbon monoxide detectors in each building were tested and operational. Most recent fire drill conducted on 1/11/26. Menus, internet accessibility and activity calendar were posted. LPA/Back up administrator observed a lock with a chain in one out of the three facility refrigerators. All refrigerators were observed unlocked (technical violation issued). According to Licensee, the facility locks that fridge at nights only and ensures that there are snacks available for clients to eat. LPA explained to Licensee that they shall submit a request for a waiver to have a locked refrigerator outlining why the refrigerator needs to be locked and how adequate and readily available snacks and beverages will be provided to clients. Licensee stated that they won't lock the fridge.

At approximately 11:15am, LPA/Back up administrator observed some walls located as follow needs to be repaired (patch/paint): wall above the heater in the living room and hallway. Main building ceiling has a crack in two different spots, glass door in main building a square glass needs to be repaired. Also, back building door needs to cover a square hole on the bottom and scratches that has exposed wood.

File review was initiated at 12:00 pm. Three staff files and five client files were reviewed. All client files have a medical assessment on file and care plans have been updated as stated per regulation. First Aid and CPR certificates for staff were current. However, the file containing staff training hours was not available for LPA to review. According to Licensee, they might file it away to the storage. Administrator Certificate for Administrator, Anthony Guevarra. 7032307735 expires 5/20/2027. Medications and medication records were reviewed. Client's weight records are updated in a monthly basis, records reviewed. Cash resources reviewed. Required postings were observed. Licensee provided updates of the following documents: Personnel Report (LIC500) and surety bond.

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. 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: 04/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/01/2026 02:17 PM - It Cannot Be Edited

Created By: Marisol Cuadra On 04/01/2026 at 01:51 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: 04/01/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in having some walls and ceiling needs to be repaired which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2026
	Plan of Correction
1 2 3 4	Licensee agrees to repair/replace items to maintain facility in good repair and will submit pictures of repairds been done to CCL by POC due date of 4/17/26.

Type B

Section Cited

CCR

80066(e)

Personnel Records

(e) All personnel records shall be maintained at the facility site. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licenseeb observation, interview and record review, the licensee did not comply with the section cited above in three out of three staff training hours file were not in the facility available for LPA to review which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/17/2026
	Plan of Correction
1 2 3 4	Licensee agrees to locate and bring staff training hour records back to the facility and maintain them available for licensing agency to review by POC due date of 4/17/26. LPA will return to review.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:

	Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/01/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

LIC809 (FAS) - (06/04)

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