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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 490112012
Report Date: 05/14/2024
Date Signed: 05/14/2024 02:59:32 PM

Substantiated


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
02/09/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240209153242
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:
05/14/2024
UNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Tony Guevarra (Licensee)TIME COMPLETED:
03:14 PM
ALLEGATION(S):
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-Staff is obstructing a facility exit door.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Licensee Tony Guevarra.

The Department received an allegation of staff is obstructing a facility exit door. Per reporting party, another agency conducted an inspection and observed the facility is locking an exit door, which prevents the residents from being able to access their secondary exit due to this door being locked. Upon inquiring about locked door, the administrator indicated that the door is kept locked per Community Care Licensing's request, as there are knives inside of the kitchen that the door is attached to. LPA conducted visits to the facility on 2/12/24 and 4/12/24. During the tour of the facility visit conducted on 2/12/24, LPA/back-up Administrator Janet Hermogenes observed in building #597 door leading to the kitchen was locked. Based on interviews conducted with back-up Administrator, the staff is under the impression that Title 22 regulation indicates the requirement to keep door always locked to prevent clients to have access to any sharp’s objects including knives or scissors.
Continues on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20240209153242
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 III
FACILITY NUMBER: 490112012
VISIT DATE: 05/14/2024
NARRATIVE
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Continued from LIC9099...

LPA had a discussion with back-up administrator to clarify regulation regarding keeping toxins or items that could pose a risk to the health and safety of clients in care in a safest location or locked cabinets instead of locking kitchen door. LPA conducted a subsequent visit on 4/12/24, during tour of the facility with Licensee, kitchen door was observed unlocked and items that could pose a risk to the health and safety of clients in care were locked in a cabinet located in the kitchen. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. **Immediate Civil Penalty assessed in the amount of $500.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
02/09/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240209153242

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:
05/14/2024
UNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Tony Guevarra (Licensee)TIME COMPLETED:
03:14 PM
ALLEGATION(S):
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-Staff made changes to the facility without notifying licensing.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Licensee Tony Guevarra.

There was an allegation received by the Department regarding staff made changes to the facility without notifying licensing. Per another’s agency report, it was observed that the facility converted the kitchen to a bedroom and did not notify licensing of this change. During the investigation, LPA submitted a request to Santa Rosa Fire Department to perform an inspection and determine if any changes were made to current facility fire clearance sketch. Based on records review, on 4/16/24, Santa Rosa Fire Department have conducted an inspection and it was determined that no violations have occurred to the current facility fire clearance. A finding that the complaint allegation of staff made changes to the facility without notifying licensing is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20240209153242
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 III
FACILITY NUMBER: 490112012
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/15/2024
Section Cited
CCR
80020(a)
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80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. This requirement has not been met as evidenced by:
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Facility will ensure all exits are always free from obstructions. Licensee will send in written statement to CCL that they understand and will be complying to regulation 80020 (a) to CCL by POC due date. **Immediate Civil Penalty assessed in the amount of $500.
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Based on LPA’s observation and interview, Licensee did not ensure fire safety by locking a fire exit door located in the kitchen exit, which is an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4