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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490110534
Report Date: 02/10/2023
Date Signed: 02/10/2023 02:31:05 PM

Document Has Been Signed on 02/10/2023 02:31 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:
02/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:02 PM
MET WITH:Chris Guevarra (House Manager)TIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required inspection and met with House Manager Chris Guevarra. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Commonly touched surfaces are disinfected at least once per day. Facility does perform daily screening of staff and residents but doesn't document it. Facility is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication. Fire extinguisher was last serviced December 2022. Smoke Detectors and Carbon Monoxide detector were operational.

Licensee will provide copies of the following documents by 2/24/23: LIC309 Administrative Organization, LIC 308 Designated Administrator, LIC 610 Emergency Disaster Plan, LIC 500 Personnel Summary, LIC400 affidavit regarding client cash resources and surety bond.

No deficiencies cited during today's inspection. Exit interview conducted with House Manager and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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