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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803259
Report Date: 05/27/2021
Date Signed: 05/27/2021 11:31:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:LE ELEN MANOR, INC.IVFACILITY NUMBER:
496803259
ADMINISTRATOR:HERMOGENES, JANETFACILITY TYPE:
740
ADDRESS:505 UMLAND DRIVETELEPHONE:
(707) 527-9656
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 5DATE:
05/27/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Janet Hermogenes (Licensee)TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Licensee, Janet Hermogenes. LPA conducted a Risk Assessment call with Licensee prior to the visit. There were 5 residents in care present at the facility.

LPA arrived at the facility and had her temperature checked and logged into a sign-in sheet. LPA/Licensee conducted a tour through the facility and observed facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet containing cleaning supplies were locked. Drawer containing knives was also locked. Facility has at least two days of perishable and one week of non-perishable foods. Medications were centrally stored and locked. Refrigerated medications were observed in a locked box in a refrigerator located in the garage. Door leading to the garage is also alarmed. Fire Extinguisher was found to be last charged on 06/2020 at the time of the visit. Smoke Detectors & Carbon monoxide detector were found to be operational during the visit. Exit doors have auditory alert system that were functional at time of visit. Administrator Certificate for Administrator Janet Hermogenes, 6013991740, expires on 10/24/21. Required postings were observed. Current residents handle their own cash resources.

Facility has submitted a mitigation program plan that was returned, Licensee and LPA went over the items and Licensee agreed to review items that needed correction and will re-submit to CCL by 6/10/2021. Posters have been placed at entrance, and facility entrance area has a designated area to screen visitors, Staff and residents are being monitored 2x/day and results are documented in a binder for each month. Facility has PPE supplies stored in the storage. Facility has a 30-day supply of medication for residents. Residents do not typically wear masks inside the facility but have them available. Facility has a designated outdoor visitation area. Facility has conducted staff training on infection control.

Licensee will submit updates of the following documents: Designation of Administrative Responsibility (LIC308), Liability Insurance. No deficiencies were cited during today's inspection.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2021
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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