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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110534
Report Date: 02/18/2022
Date Signed: 02/18/2022 11:12:15 AM

Document Has Been Signed on 02/18/2022 11:12 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, 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: 18DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:47 AM
MET WITH:Tony Guevarra (Licensee)TIME COMPLETED:
11:22 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee, Tony Guevarra and Administrator, Chis Guevarra. LPA/Licensee/Administrator reviewed PIN 22-05, 22-06, 22-07 and 22-09.

LPA arrived at the facility and attempted to had their temperature checked, but thermometer was not working then it was logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Administrator conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least once a day. Facility has designated an outdoor area for visitation. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Based on records review, staff and residents had not being monitored daily and results are not documented since May 2021. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate. However, not all of them have received boosters. Clients do not typically wear a mask while in the facility, but they do wear masks when in the community. Clients do not attend to wellness program due to covid19 restrictions but they do other activities at the facility. Clients do not receive indoor visitation just outdoors. Facility has submitted their Covid Mitigation Plan and approved on 7/14/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff.
Licensee agreed to provide updates of the following by 2/25/22: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), affidavit regarding client/resident cash resources (LIC400), 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2022
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 02/18/2022 11:12 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 02/18/2022 at 10:56 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
, 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: 02/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)

80072 Personal Rights (a)... residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, Licensee did not ensure the personal rights of persons in care to safe & health accommodations. Facility is not screening and documenting staff and residents for Covid19 symptoms to prevent the spread of the virus and to be in compliance with CCL guidelines which poses/posed an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/19/2022
Plan of Correction
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Licensee/Administrator will ensure Personal Rights of residents are maintained. Licensee agrees to submit proof of training for all staff to conduct screening and documenting for Covid19 symptoms to CCL by close of business 2/19/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022


LIC809 (FAS) - (06/04)
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