Community Care Licensing

Document Has Been Signed on 04/19/2024 01:06 PM - It Cannot Be Edited

FACILITY NAME:	LE ELEN MANOR II		FACILITY NUMBER:	490110534
ADMINISTRATOR/ DIRECTOR:	GUEVARRA, ANTHONY D		FACILITY TYPE:	735
ADDRESS:	3467 PHILLIPS AVE.		TELEPHONE:	(707) 573-4705
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY: 20		CENSUS: 18	DATE:	04/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:35 AM
MET WITH:	Chris Guevarra (House Manager)		TIME VISIT/ INSPECTION COMPLETED:	01:20 PM

SUPERVISORS NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024

FACILITY NAME: LE ELEN MANOR II	FACILITY NUMBER: 490110534
	VISIT DATE: 04/19/2024

FACILITY NAME: LE ELEN MANOR II	FACILITY NUMBER: 490110534
	VISIT DATE: 04/19/2024

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR II	FACILITY NUMBER: 490110534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2024

Type A

Section Cited

CCR

80087(a)

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/house manager observation, interview and record review, the licensee did not comply with the section cited above in ensuring the sanitary and good repair of the facility for the safety and well-being of clients, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/20/2024
	Plan of Correction
1 2 3 4	Licensee to complete repairs and replacement of items that need to be changed as well as discard debris furniture observed. Items that need to be completed are the following: window screen at the front door, two window screens in the porch area, faucet located in bathroom located in building #1, nails exposed that needed to be repaired, toilet located at building #3 needs to be fix (attach receipt as proof of repair). Room #13, 14 and 15 located at building #3 needs to have a door installed. Photos and receipts will be submitted to CCL as proof of correction by POC due date.

Type A

Section Cited

CCR

85088(c)

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/House manager observed that bathrooms do not have toilet paper as stated per regulation, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/20/2024
	Plan of Correction
1 2 3 4	The facility will provide a supply of toilet paper to clients in care and will implement a system ensuring that they provide clients with supplies necessary for client's personal care and maintenance of their personal hygiene. Licensee will submit a written plan to CCL by POC due date.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR II	FACILITY NUMBER: 490110534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2024

Type B

Section Cited

CCR

80021(a)(2)

(2) Subsequent to initial licensure, the licensee shall provide evidence of a bacteriological analysis of the private water supply as frequently as is necessary to ensure the safety of the clients, but no less frequently than specified in the following table: For a licensed capacity of 6 or fewer analysis is required at initial licensing and subsequent analysis is not required unless evidence supports the need for such analysis to protect clients. For a licensed capacity of 7 through 15 analysis is required at initial licensing and subsequent analysis is required annually. For a licensed capacity of 16 through 24 analysis is required at initial licensing and subsequent analysis is required semiannually. For a licensed capacity of 25 or more analysis is required at initial licensing and subsequent analysis is required quarterly. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/house manager observation, interview and file reviews, required semi-annual water bacterial analysis not completed, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee shall provide evidence of a bacteriological analysis of the private water supply as frequently as is necessary to ensure the safety of the clients, Submit copy of the water bacteriological analysis report to CCL by POC due to clear the citation 5/3/24.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR II	FACILITY NUMBER: 490110534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2024

Type B

Section Cited

CCR

85088(c)(2)

(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/house manager observed that several client's rooms do not have a chair available in their bedrooms, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee to provide clients with a chair as stated per regulation. Licensee will submit receipt of purchase to CCL as proof of correction by POC due date.

Type B

Section Cited

CCR

80026(h)(1)

(h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: (1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting, with columns for income, disbursements and balance, for each client. Supporting receipts for purchases shall be filed in chronological order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/house manager reviewed client's cash Resources, but there were some discrepancies between cash on hand and general ledgers, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to ensure that current accurate records are available at the facility at all times per Title 22 regulations. Licensee will review current cash resources to ensure accuracy of records are maintained at all times. Licensee will submit a written plan about how they will maintain that ledger records current/accurate as per Title 22 Regulations to CCL by POC due date 5/3/2024.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR II	FACILITY NUMBER: 490110534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2024

Type B

Section Cited

CCR

80061(b)

(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/house manager observation, interview and record review, the licensee did not comply with the section cited above in several incidents of hospitalizations that occured involving clients have not been reported to CCL, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee to enssure all incidents are reported as required by regulation. Licensee to submit plan of future compliance with this regulation, and hold an in-service training on reporting requirements with all staff. Licensee will submit proof of training with compliance plan by POC due date of 5/3/24.

Type B

Section Cited

HSC

1537.1(a)

(a) A licensee of a residential facility serving adults that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for client use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/house manager observation, interviews and record review, the licensee did not comply with the section cited above in providing clients in care with at least one internet access device dedicated for client use, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee agrees to provide clients in care with at least one internet access device dedicated for client use. Licensee will submit receipt of purchase of device to CCL by POC due date.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR II	FACILITY NUMBER: 490110534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2024

Type B

Section Cited

CCR

85068.3(a)

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's house manager observation, interviews and records review, the licensee did not comply with the section cited above in 5 out of 5 client's care plans have not been updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee will review all client's files to ensure that each client have a current care plan on file and will submit LIC9098 self-certification form to CCL as proof of correction ensuring that files are current by POC due date to clear the citation.

Type B

Section Cited

CCR

80075(k)(7)

(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/house manager observation, interview and record review, the licensee did not comply with the section cited above in 5 out of 5 medication records reviewed revealed that the facility has not been maintaining records accurately of Centrally Stored Medication Logs, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee will review all client's medication records to ensure that each client have their centrally stored medication log accurate as stated per regulation and train staff responsible for dispensing medications to receive training from an outside vendor and will submit proof of staff training and LIC9098 self-certification form to CCL as proof of correction ensuring that files are current by POC due date to clear the citation.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR II	FACILITY NUMBER: 490110534
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/19/2024

Type B

Section Cited

HSC

1565(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, interview and file reviews, facility quarterly drills were not conducted, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Licensee to submit plan of correction on how the facility will ensure to hold quarterly drills as required by Health & Safety Code to CCL by POC due date 5/3/24.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 04/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/19/2024