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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 490112012
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:48:49 PM

Document Has Been Signed on 06/18/2024 01:48 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 IIIFACILITY NUMBER:
490112012
ADMINISTRATOR/
DIRECTOR:
GUEVARRA, ANTHONY DFACILITY TYPE:
735
ADDRESS:597 GRANDBERG COURTTELEPHONE:
(707) 545-1045
CITY:SANTA ROSASTATE: CAZIP CODE:
95407
CAPACITY: 12CENSUS: 7DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:18 AM
MET WITH:Tony Guevarra (Licensee)TIME VISIT/
INSPECTION COMPLETED:
02:03 PM
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Licensing Program Analyst (LPA), Cuadra, arrived unannounced to conduct an Annual Required Inspection and met with Licensee, Tony Guevarra. Fees are current. Contact information reviewed.

LPA/Licensee initiated a tour of the facility at 11:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Client rooms were furnished per regulation. Water temperature in client's bathroom measured at 106, 108.7 and 117.1 degrees F which are within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Cash resources and records were reviewed. Fire extinguisher was last inspected October, 2023. Smoke detectors and carbon monoxide located throughout the facility were tested and operational. Fire/Disaster drill was conducted April 21, 2024.

File review was initiated at 12:00 pm. Two staff files and five client files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for administrator Anthony Guevarra 6008632735 expires on 5/19/2025. Medications and medication records were reviewed. Required postings observed.

Licensee submitted updates of the following documents: Designation of Administrative Responsibility (LIC308), control of property and Personnel Report (LIC500).
No deficiencies cited during today's visit. Exit interview conducted with licensee and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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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