<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 02/18/2022
Date Signed: 02/18/2022 10:26:36 AM


Document Has Been Signed on 02/18/2022 10:26 AM - 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:BETSY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
496800803
ADMINISTRATOR:LUNINGNING ALICDANFACILITY TYPE:
740
ADDRESS:1923 FALLEN LEAF DR.TELEPHONE:
(707) 545-1160
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: 4DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Edward AlicdanTIME COMPLETED:
10:40 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Erik Gonzalez Campos arrived unannounced to conduct a Required - 1 Year inspection at approximately 8:30 AM, and met with staff, Edward Alicdan. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon entry LPA was screened for COVID symptoms and asked to sign in by staff. At primary entrance LPA observed visitor sign-in sheet. LPA conducted walk through of the facility with staff and observed COVID postings throughout. Mitigation plan was submitted by licensee and reviewed by Community Care Licensing.

Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is kept throughout the facility. Per staff, updated infection control guidelines and PINs are communicated to responsible parties verbally. Staff have not been N95 fit tested. High touch surface areas are disinfected daily. Due to current facility census residents could isolate in their own rooms if they became ill. LPA observed necessary PPE to support a resident in isolation. Residents are monitored daily for symptoms and screened upon returning from outings

Residents' emergency contact information has been updated and staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible to residents under the kitchen sink and in garage. Medications are centrally stored and inaccessible to residents on a locked medication cart. All residents have received their booster shot. All staff have received their booster shot. Facility is not currently conducting surveillance testing but has a supply of antigen testing kits.

Continued on LIC 809C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: BETSY'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 496800803
VISIT DATE: 02/18/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Facility is allowing residents to have meals in the dining room and furniture is set up for social distancing. Common areas are also set up for social distancing.

Facility is not currently allowing visitation indoors unless a visitor is fully vaccinated. LPA provided guidance to review PIN 22-07 and indicated that visitors who do not meet vaccination requirements may visit indoors with proof of negative test.

LPA requested the following documents during the visit:

LIC 500
LIC 308
Liability Insurance
Emergency Disaster Plan

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2