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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110534
Report Date: 09/08/2022
Date Signed: 09/08/2022 02:13:56 PM

Document Has Been Signed on 09/08/2022 02:13 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: 16DATE:
09/08/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:48 PM
MET WITH:Chris Guevarra (House Manager)TIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Case Management inspection and and met with House Manager Chris Guevarra and explained the reason of the visit is amending findings report dated 8/23/2022. The document requires amending because personal identification was showing by error on original LIC9099 and the amended document deletes reference to the person. LPA removed the name in LIC9099. Report was amended and signed today, 9/8/2022.

During today's visit, LPA noticed that a Plan of Correction (POC) has not been submitted to CCL about deficiency #80076 (a)(5) cited on 8/23/22. House Manager requested an extension and LPA agreed to give an extension of plan of correction until 9/9/22 by the end of business day.

No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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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