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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490112012
Report Date: 02/15/2022
Date Signed: 02/15/2022 10:41:38 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/07/2022 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20220207144256
FACILITY NAME:LE ELEN MANOR IIIFACILITY NUMBER:
490112012
ADMINISTRATOR:GUEVARRA, ANTHONY DFACILITY TYPE:
735
ADDRESS:597 GRANDBERG COURTTELEPHONE:
(707) 545-1045
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY:12CENSUS: 8DATE:
02/15/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tony GuevarraTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Personal Rights Violation
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrived unannounced and met with the Administrator for the purpose of delivering findings on this complaint. It has been alleged that the Administrator has threatened the Client (C1) with eviction for misconduct and insisting that C1 be administered mood altering drugs. This Department has investigated this complaint by making site visit; taking statements from staff and clients residing in the facility; obtaining and reviewing documents. The following determinations are made: C1 admits to breaking house rules; Administrator denies threatening C1 but admits to voicing consequences to continuous breaking of house rules by C1; C1's medical and case work records document a history of serious mental illness, substance abuse, and difficulty with personal relationships; Five of five clients interviewed indicate C1 does not follow house rules and can be uncooperative with Administrator; Four of five clients interviewed characterize Administrator as kind. Although the allegation may be true, based upon the statements and documents, the preponderance of evidence standard has not been met. Therefore, the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Carla Martinez
LICENSING EVALUATOR NAME: David Leibert
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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