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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490110534
Report Date: 04/02/2025
Date Signed: 04/02/2025 10:55:07 AM

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
02/04/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250204142024
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:
04/02/2025
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Tony Guevarra (Licensee)TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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-Staff did not ensure a client was properly fed while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Tony Guevarra (Licensee).

The Department received an allegation of staff did not ensure a client was properly fed while in care. Per Reporting party, client (C1) appeared malnourished as indicated by a sunken face appearance. Upon further inquire, the reporting party learned that C1 was refusing meals, they had recently fainted, and ambulance was called by the facility staff, but C1 refused medical care. Although, C1 fainted again, refused food, and paramedics were contacted again who transport them to the hospital for further evaluation. The facility self-reported the incident on 2/3/25 confirmed that around 8am after breakfast, C1 attempted to walk to the front of the main building, but they fainted, staff called paramedics, but C1 refused medical care. Later in the afternoon around 6:30pm while C1 was sitting down in the living room watching tv, C1 was just staring at the tv, but not responding to any of them. Continue on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20250204142024
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: 04/02/2025
NARRATIVE
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Continued from LIC9099...

Once again, paramedics were contacted, they attempted to talk to C1, but they were not responding, and they transport them to the hospital for further evaluation. On 2/8/25, C1 passed away while they were hospitalized. Based on records review, C1 was admitted to the facility since May 5, 2001. C1’s weight record logs indicates that C1’s weight was 101 pounds in March 2015, which it was the last weight documented by the facility. C1’s physician report dated 2/13/24 indicates that C1 declined dentures and did not have any teeth. However, there was no indication of special diet. Although, the facility was able to provide LPA with an after-visit summary for C1 dated 2/13/24 where indicates that C1’s weight was 93 pounds and had a follow up appointment within 6 weeks on 3/26/24 for weight check and nutrient supplements follow up appointment. C1’s prescription order confirms that there was a doctor’s order for ensure liquid one bottle orally three times daily. However, it was confirmed by C1’s responsible party that they were fulfilling C1’s prescription order. On 2/26/25, Licensee provided LPA with C1’s death certificate indicating cause of death was due to acute respiration failure with hypoxia as a subsequent underlying cause of death pneumonia. Other conditions that contributed to death were chronic obstructive pulmonary disease, acute kidney injury and septic shock. A finding that the complaint allegation occurs of staff did not ensure a client was properly fed while in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2