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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803259
Report Date: 04/14/2022
Date Signed: 04/14/2022 03:20:25 PM


Document Has Been Signed on 04/14/2022 03:20 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, INC.IVFACILITY NUMBER:
496803259
ADMINISTRATOR:HERMOGENES, JANETFACILITY TYPE:
740
ADDRESS:505 UMLAND DRIVETELEPHONE:
(707) 527-9656
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 4DATE:
04/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:28 PM
MET WITH:Janet Hermogenes (Administrator)TIME COMPLETED:
03:30 PM
NARRATIVE
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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 with staff at the facility. There were 4 residents in care present at the facility.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were not wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least two times a day. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are not monitoring and documenting results. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate and received boosters for staff and residents. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents are allowed to receive indoor visitation with their families and facility performs antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 8/4/21. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff. LPA/Administrator reviewed PIN 22-05, 22-06, 22-07 & 22-09. Administrator agreed to provide updates of the following by 4/21/22: Designation of Administrative Responsibility (LIC308), Affidavit regarding client cash resources (LIC400), Personnel Report (LIC500), Liability insurance.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
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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Document Has Been Signed on 04/14/2022 03:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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, INC.IV
FACILITY NUMBER: 496803259

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, interview and record review Licensee did not ensure S1 was wearing a mask. Also, staff and residents daily temperatures documented as reflected in facility's mitigation plan and current CCL requirements. This poses an immediate risk to the health, safety and personal rights to the residents in care.
POC Due Date: 04/15/2022
Plan of Correction
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Licensee will ensure Personal Rights of residents are maintained. Licensee agrees to submit proof of training for mask requirement for all staff to LPA by close of business 4/15/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/14/2022
LIC809 (FAS) - (06/04)
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