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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 03/29/2024
Date Signed: 03/29/2024 11:58:56 AM


Document Has Been Signed on 03/29/2024 11:58 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
SANTA ROSA RO, 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: DATE:
03/29/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Luningning Alicdan, LicenseeTIME COMPLETED:
12:00 PM
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Licensing Program Manager Victoria Bertozzi and Licensing Program Analyst Christi Coppo conducted an informal office meeting, and met with Licensee/Administrator, Luningning "Bot" Alicdan.

This informal meeting is being conducted to discuss concerns identified in regards to the following areas:
  • Physical plant issues
  • Staff training
  • Personal rights
  • Medication
  • Resident Records
  • Bedridden fire clearance

LPM offered TSP services, Licensee expressed interest in participating in the Department's Technical Support Program. LPM will obtain further information regarding the program. Licensee must review Title 22 regulation and their Plan of Operation to ensure compliance. Continued non-compliance may result in a Non-Compliance Plan. Licensee and LPA discussed new employee at Fallen Leaf and Licensee will send over Health screen, training, 1st Aid and CPR.

Exit interview conducted with Licensee and a copy of this report was given.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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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