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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110534
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:51:04 PM

Document Has Been Signed on 06/28/2022 12:51 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: DATE:
06/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Tony Guevarra (Licensee)TIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management inspection and met with Licensee Tony Guevarra. The purpose of this case management inspection is to follow up on a phone call and self-report incident report submit to Community Care Licensing (CCL).

CCL received a call from Licensee on 6/27/22 and self-reported incident report on 6/28/2022 reporting an incident that occurred on 6/26/2022. Client (C1) went AWOL in the morning of June 26, 2022 the Administrator noticed C1 walking to the street towards the Starbucks store. Administrator stopped them and remind them to make sure to come back early and C1 replied “yes at 8:30pm”. Administrator noticed that C1 did not come back at the time agreed then contacted C1’s responsible party and filed a police report for a missing person case# 2206-27-006. During today’s visit LPA was informed by Licensee that C1 was still AWOL and the police have not been able to locate them. LPA was provided with C1’s Physician Report (LIC 602) dated 5/26/2020 which indicates that C1 can leave the facility without supervision. This is not the first AWOL attempt by C1 and there had been another incident. C1’s care plan dated 1/20/22 indicates that C1 is a very quiet person who doesn’t like to socialize. After LPA reviewed resident records, it was requested to the Licensee once C1 returns to update their care plan for review.

No deficiencies cited during today’s inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/28/2022
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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