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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803259
Report Date: 02/19/2025
Date Signed: 02/19/2025 10:16:57 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/25/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241125153637
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:
02/19/2025
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Janet Hermogenes (Licensee)TIME COMPLETED:
10:31 AM
ALLEGATION(S):
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-Personal Rights.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Janet Hermogenes, Licensee.

The Department received an allegation of Personal Rights. Per Reporting party, staff (S1) was observed pressuring resident (R1) to finish their meal even after R1 stated that they didn't want any more. S1 told R1: “your doctor says you need to eat more due to blood sugar balance”. R1 replied: “my doctor said I am not diabetic”. This went on for a couple of rounds and other residents were observed clearly uncomfortable with the psychological abuse of having to witness Licensee’s behavior day after day. Also, Licensee have been observed making fun of R1 and threatening them by saying: “if you can’t do this (referring to chores), then you can’t smoke”. According to the reporting party, all residents are fearful of retaliation by Licensee and/or risking the stability of their housing because Licensee tends to pick on the most vulnerable members of the house and have threatened them by saying: “if they don’t like it, they can give a 30-day notice”.
Continue on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/25/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241125153637

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:
02/19/2025
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Janet Hermogenes (Licensee)TIME COMPLETED:
10:31 AM
ALLEGATION(S):
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--Staff is not assisting residents with their medication as prescribed by their physician.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Janet Hermogenes, Licensee.
Regarding allegation of staff is not assisting residents with their medication as prescribed by their physician. The reporting party alleges that staff are withholding pain medication (not sure If it Is PRN or prescribed). Based on records review of medication and their records of resident’s centrally stored medication logs for the timeframe of November 9, 2024-December 8, 2024, there was no discrepancies found regarding medication logs. Based on LPA’s interviews conducted with staff and residents did not reveal any other concern other than the Licensee making fun of resident’s (R1) pain by stating: “your back is not hurting when you smoke cigarettes, but then hurts when they are asked to do things”, these comments against resident’s personal rights are being addressed on LIC9099 report. A finding that the complaint allegation occurs of staff is not assisting residents with their medication as prescribed by their physician is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20241125153637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 02/19/2025
NARRATIVE
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Continued from LIC9099...

Another situation happens when Licensee attends to resident’s psychiatrist appointment by not providing privacy for the residents and the Licensee do not allow residents to participate in the decision-making of their care planning. Based on interviews conducted with residents (R1, R2, R3 & R4) and staff (S1 & S2), it was revealed that Licensee (S1) and staff (S2) yells at residents in average of two to three times per day, S2 yells “why are you wasting food?”, S1 tells another resident “You must eat all your food”, Licensee will yell at another resident because this resident “does not get it”. Licensee confirmed that there is one resident (R1) who had problems with their diet because when R1 was diagnosed with a urinary tract infection (UTI) didn’t want to eat enough as encouraged by their physician to eat a little bit more. However, based on records review of doctor’s visit on 11/6/24 indicates that R1 had elevated glucose reading. LPA was unable to determine if it was consented or not for Licensee to be present at psychiatrist visits. The Licensee also confirmed their presence into the resident’s psychiatrist appointments to get information about their health, but they leave them alone after the Licensee bring up their concerns. Although, LPA was unable to receive confirmation from R1 if this practice bothers them or not. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The Department will review information obtained to determine if any further action is needed.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20241125153637
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
HSC
1569.269(a)(1)
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§1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidence by:

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Licensee agrees to review regulation 1569.269 (a)(1) with staff and submit self-certification that it has been completed, and personal rights of residents outlined by regulation will never be violated by POC due date.
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Based on interviews with residents and staff, the facility staff (S1 & S2) yells at residents in average of two to three times per day and Licensee admitted their presence into the resident’s psychiatrist appointments, which poses an immediate risk to the health and safety of clients in care.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4