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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803259
Report Date: 11/19/2021
Date Signed: 11/19/2021 02:53:04 PM

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: 6DATE:
11/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Janet Hermogenes (Administrator)TIME COMPLETED:
03:00 PM
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LPA Cuadra arrived unannounced to conduct a case management inspection and met with Administrator, Janet Hermogenes. LPA conducted risk assessment with Administrator. LPA arrived at the facility and had her temperature checked and was logged into a sign-in sheet.

LPA is following up on an incident received on 11/15/21 from Administrator regarding client (C1). On 11/13/21 around 8am Administrator overheard C1 talking to another client about a dog incident and inquired what happened and was told by C1 that they got bit by a dog the day before and Administrator inquired why they did not inform her about the incident and C1 replied back that they didn't said anything because it doesn't hurt and was not bleeding. Administrator took client immediately to the emergency room for an evaluation, C1 received a tetanus shot and was prescribed with antibiotics for 10 days. Administrator notified responsible parties.

During today's visit LPA reviewed C1's physician report dated 2/9/21 that indicates that client is allowed to leave the facility unassisted. However, Administrator had advised C1 to take precautions in the future when walking around the neighborhood.

No deficiencies 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: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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