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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 02/24/2023
Date Signed: 02/24/2023 01:27:30 PM


Document Has Been Signed on 02/24/2023 01:27 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: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: 6DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Staff, Edward AlicdanTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 02/24/2023 to conduct a required - 1 year inspection. LPA was greeted and screened by staff. LPA met with staff, Edward Alicdan. This inspection is focused on the infection control practices and procedures of this facility.

LPA toured building and grounds which were found to be clean and in good repair. Facility currently has six residents. Facility had sufficient perishable and non-perishable food. Fire extinguishers inspected were charged and current. Toxins were locked and secured. Medications were centrally stored and locked. Carbon monoxide and smoke detectors were present and operational. Walkways were cleared and unobstructed. High touch surface areas are disinfected daily. LPA observed COVID postings at the front entrance. Staff and residents are all fully vaccinated. Facility has necessary Personal Protective Equipment to support a resident in isolation. LPA and administrator discussed resident/staff record keeping. Staff and visitors were observed wearing masks.

LPA requested the following documents be submitted to Community Care Licensing within 30 days of today's inspection:

LIC 308 Designation of Facility Responsibility
Liability Insurance
LIC 610 Emergency Disaster Plan
LIC 9020 Resident Roster
LIC 500 Personnel Report

No deficiencies observed during today's inspection. Exit interview conducted with Edward Alicdan and a copy of the report emailed to facility.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Erik Gonzalez CamposTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023
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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