Community Care Licensing

Document Has Been Signed on 07/18/2023 02:59 PM - It Cannot Be Edited

FACILITY NAME:	LE ELEN MANOR III		FACILITY NUMBER:	490112012
ADMINISTRATOR:	GUEVARRA, ANTHONY D		FACILITY TYPE:	735
ADDRESS:	597 GRANDBERG COURT		TELEPHONE:	(707) 545-1045
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95407
CAPACITY: 12		CENSUS: 7	DATE:	07/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:04 PM
MET WITH:	Tony Guevarra (Licensee)		TIME COMPLETED:	03:14 PM

SUPERVISORS NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

FACILITY NAME: LE ELEN MANOR III	FACILITY NUMBER: 490112012
	VISIT DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR III	FACILITY NUMBER: 490112012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

Type A

Section Cited

CCR

80088(e)(1)

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Licensee observation and interview, Licensee did not comply with the section cited above in two out of three bathrooms used by residents in care water temperature were not within regulation, posing an immediate health, safety and personal rights risk to residents in care.
	POC Due Date: 07/19/2023
	Plan of Correction
1 2 3 4	Licensee to ensure water temperature is within regulatory guidelines. Licensee adjusted water temperature within regulation. Licensee agrees to send self - certfication that water temperature will be monitored for one week to CCL by POC date.

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: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023

Link to Parent Document Below:

FACILITY NAME: LE ELEN MANOR III	FACILITY NUMBER: 490112012
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/18/2023

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/Licensee observation, interview and record review, the facility staff did not comply with the section cited above in 7 out of 7 resident's care plan assessments were not performed within the last 12 months as indicated per regulation, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Licensee agreed to provide evidence through self-certification (LIC9098 form) of current care plan assessments for 7 resident to CCL by POC due date.

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/Licensee observation, interview and record review, the licensee did not comply with the section cited above. Last disaster drill was not conducted at least every quarter which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2023
	Plan of Correction
1 2 3 4	Licensee agreed to conduct a quarterly disaster drill. Licensee will submit a self-certification form LIC9098 that current disaster drill have been conducted within the last quarter to clear the citation by POC due date.

SUPERVISOR'S NAME: Bethany Moellers LICENSING EVALUATOR NAME: Marisol Cuadra LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2023