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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490110534
Report Date: 11/20/2023
Date Signed: 11/20/2023 02:37:11 PM

Unsubstantiated


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
11/01/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231101145816
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: 16DATE:
11/20/2023
UNANNOUNCEDTIME BEGAN:
01:47 PM
MET WITH:Chris Gevarra (House Manager)TIME COMPLETED:
02:52 PM
ALLEGATION(S):
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Staff do not provide proper supervision to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced at the facility and met with house manager Chris Guevarra to deliver findings regarding the complaint allegations above.

A complaint received alleges that staff do not provide proper supervision to residents. Per reporting party, residents appear to be completely unsupervised, because they are constantly out in the neighborhood smoking marijuana, getting in the way of vehicles on the road, and panhandling at the local mini mart. Previously, the reporting party have unsuccessfully attempted to address the issues with the house manager, who expressed that they are basically powerless. After the conversation, the issues seemed to be resolved for three days only and the reporting party is only requesting that the residents stay on their property. Based on records review, the facility provided LPA with personnel report (LIC500) that reflects that the facility has staff to care and assist clients in care, and the facility has a variety of activities scheduled for the month of November 2023 including bingo, football, wellness programs, etc.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
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 2
Control Number 21-AS-20231101145816
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
VISIT DATE: 11/20/2023
NARRATIVE
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Continue on LIC9099...

However, it appears that clients at times do not have interest in participating, which is their right to choose not to participate. Also, LPA obtained and reviewed all client’s physician reports (LIC602) that indicated that they are allowed to be out in a community unassisted. Although, on 11/2/23 LPA conducted interviews with house manager, who is aware of concerns with clients independently going out to the community. which have been addressed to their case managers. Due to The Department’s inability to enforce Title 22 regulations when clients are out in the community, LPA have advice reporting party to call law enforcement if they feel like clients are causing any harm in the community. A finding that the complaint allegation staff do not provide proper supervision to residents 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2