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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803259
Report Date: 04/28/2023
Date Signed: 04/28/2023 12:00:04 PM


Document Has Been Signed on 04/28/2023 12:00 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: 5DATE:
04/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Janet Hermogenes (Licensee)TIME COMPLETED:
11:57 AM
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Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct an Annual Required inspection and was greeted by Licensee Janet Hermogenes.

LPA/Licensee initiated a tour of the facility around 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Water temperature in resident bathroom measured between 107.2 and 114.4 degrees F which are within allowable range of 105 to 120 degrees F. Cabinet in kitchen containing cleaning supplies and cabinet containing knives was locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Bathrooms had required bath mats and grab bars. 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 last inspected September 2022. Smoke detectors and carbon monoxide detector located throughout the facility were tested and operational. Exit doors have auditory alert system and were functional at time of visit. Most recent fire/disaster drill was conducted November, 2022. Required postings were observed. Two staff files and five resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Janet Hermogenes, 6013991740, expires on 10/24/23. Medications and medication records were reviewed. Current residents handle their own cash resources. Activity calendar was observed and residents attend to Wellness Program. Facility has emergency supplies including flashlights. First aid kit fully stocked.

Licensee provided updates of the following documents: Liability Insurance, LIC 500 Personnel Summary,
LIC308 Designation of Facility Responsibility, LIC 610 Emergency Disaster Plan and surety bond.

No deficiencies were cited during today's visit. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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