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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 02/08/2024
Date Signed: 02/08/2024 05:20:58 PM


Document Has Been Signed on 02/08/2024 05:20 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
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: 3DATE:
02/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Luningning Alicdan, AdministratorTIME COMPLETED:
05:35 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Licensees (Bot) and Edward Alicdan arrived later. Facility currently has 3 residents in care one of which is on hospice, which is allowable per the facility's Hospice Waiver. .

At approximately 9:00am LPA and Licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. LPA and Licensee observed the following food items to not be covered or labeled: sliced cake, 1/2 of a tomato, brown liquid in a cup, and red sauce in a bowl. Per Title 22 regulation 87555(b)(9) General Food Service Requirements - (b) The following food service requirements shall apply: (9)Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service (deficiency cited, see 809D). LPA and Licensee observed one bowl of cooked pasta on stove top in cooking pot not properly covered. Per Licensee, pasta left out overnight and during the day before, at room temperature. Per Title 22 regulation 87555(b)(23) General Food Service Requirements (b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures (deficiency cited, see 809D). LPA and Licensee observed kitchen drawer containing sharp knives not locked. Per Title 22 regulation 87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) (deficiency cited, 809D).



All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. LPA and Licensee observed rash bins in residents rooms are not covered. Per Licensee, trash bin in R2's room contained soiled brief for at least 2 days. Per Title 22 regulation 87303(f)(3) Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof (deficiency cited, see 809D).
Continued on 809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
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 12


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803
VISIT DATE: 02/08/2024
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 Continued from 809...

Resident bathrooms had required bath mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 112.2 and 114 degrees F respectively, which is within the allowable range of 105 to 120 degrees F. LPA observed a 64 ounce jug of bleach accessible in the hallway shower and there was approximately 4 ounces remaining in the jug. Unlocked hallway closet had toxins accessible including acetone and disinfectants. Per Title 22 regulation 87705(f)(2) Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.(deficiency cited, see 809).

Fire extinguishers were last inspected 7/14/2023. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Per LPA and Licensee observation and record review, facility has not conducted quarterly disaster drill since 2020, as documented in disaster drill paperwork. Licensee began to fill out fire drill paperwork dating it with a date in the future (2/10/2024) and signing the names of the attendees with date of attendance. LPA advised facility can not do the paperwork prior to conducting the actual drill as it may appear that the drill was not actually completed. Per Health and Safety Code HSC 1569.695(c) - Other Provisions (c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenario... Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill (deficiency cited, see 809D). Facility has a backup generator for use during a power outage.

Upon LPA arrival to facility at approximately 8:45am, LPA observed medication cart in living room to be unlocked. All medication stored in cart was accessible to residents. Per Title 22 regulation 87465(h)(2) Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for...the centrally stored medication (deficiency cited, see 809D).

Continued on 809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803
VISIT DATE: 02/08/2024
NARRATIVE
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Continued from 809C...

At approximately 9:15am LPA and Licensee observed unlocked drawer in kitchen to contain prescription Tramadol, unwrapped insulin syringe, and pre-poured medication in dishes. Per Title 22 regulation 87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers (deficiency cited, see 809D). Syringe for insulin found accessible in unlocked kitchen drawer. Syringe was unwrapped from packaging and possibly was used. Per Title 22 regulation 87303(f)(2) Maintenance and Operation (f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens (deficiency cited, see 809D).

At approximately 10:00am LPA observed resident's bathroom shower (R3) in room #1 to have the drywall/sheet rock missing from around shower spigot and pipe(s) exposed. Per Title 22 regulation 87307(d)(2) Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment (deficiency cited, see 809D).

At approximately 1:00pm LPA conducted a review of three resident records. Facility has one resident (R1) that is bedridden but does not have bedridden fire clearance and could not produce proof of notification to fire department. Per Title 22 regulation 87606 Care of Bedridden Residents (b) A facility shall notify the local fire jurisdiction within 48 hours of accepting or retaining any bedridden person, as specified in Health and Safety Code Section 1569.72(f).(deficiency cited, see 809D). Resident (R1) did not have a current LIC602 Physician's Report, last report dated 2022. Per Title 22 regualtion 87705(c) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually... (deficiency cited, see 809). R1 did not have a current Appraisal Needs and Services plan (Care plan) on file. Per Title 22 regulation 87705(c) Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals (deficiency cited, see 809D).

Continued on 809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 12
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803
VISIT DATE: 02/08/2024
NARRATIVE
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Continued from 809C...

At approximately 2:00pm LPA conducted a review of two staff records. Both staff (S1 and S2) were missing required training. Per Health and Safety Code HSC 1569.695(b)(2)87458(b)(1) (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training (deficiency cited, see 809D). Staff (S1) did not have Health Screen on file. Per Title 22 regulation 87412 Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(11) A health screening as specified in Section 87411, Personnel Requirements - General (deficiency cited, see 809D).

Luningning Alicdan, Administrator Certificate 6010428740 expired October 2023; however, certificate is currently in Renewal-Pending status. All fees are current as of this time.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:

LIC500- Personnel Report
LIC308- Designation of Responsibility
Evidence of Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with Licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 02/08/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
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Based on LPA and Licnsee observation the licensee did not comply with the section cited above because: med cart in living room to be unlocked, all medication accessible to residents, unlocked drawer in kitchen contained: prescription Tramodal, unwrapped syringe, and pre-poured medication in dishes, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction dated of 2/9/2024. Training to be completed and log provided to CCL by no later than 2/16/2024
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA and Licensee observation, the licensee did not comply with the section cited above as LPA and Licensee observed unlocked drawer in kitchen to contain pre-poured medication in dishes. LPA and Licensee observed pillboxes in living room stacked on chair by the computer which contained medications, to be accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction dated of 2/9/2024. Training to be completed and log provided to CCL by no later than 2/16/2024
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 5 of 12


Document Has Been Signed on 02/08/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87606(b)
Care of Bedridden Residents
(b) A facility shall notify the local fire jurisdiction within 48 hours of accepting or retaining any bedridden person, as specified in Health and Safety Code Section 1569.72(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA interview with Licensee, the licensee did not comply with the section cited above in that facility has one resident (R1) that is bedridden but facility does not have bedridden fire clearance and could not produce proof of notification to fire deptartment, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Facility to produce proof of notification of bedridden status to Santa Rosa Fire Department by POC due date.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that a 64 ounce jug of bleach was accessible in the hallway shower which conained approximately 4 ounces remaining in the jug. Unlocked hallway closet had toxins accessible including acetone and disinfectants, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/09/2024
Plan of Correction
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Facility to submit plan on how they will store toxins to be in compliance with regualtion 87705(f)(2) by POC due date. Facility to complete staff training on proper storage of toxins and subnit to CCL training log no later than 2/16/2024. Facility to submit picture of locking closet doorknob.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 6 of 12


Document Has Been Signed on 02/08/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that a plastic container on side of house was filled with brown liquid and old tools covered in orange and brown spots, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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Facility cleared and cleaned bin during LPA inspection. Deficiency cleared.
Type B
Section Cited
CCR
87303(f)(2)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (2) Syringes and needles are disposed of in accordance with the California Code of Regulations, Title 8, Section 5193 concerning bloodborne pathogens.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that syringe for insulin was found accessible in unlocked kitchen drawer. Syringe was unwrapped from packaging and possibly used, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Facility to submit to CCL a plan to train staff to properly store syringes. Plan due by plan of correction date of 2/16/2024. Training to be completed and log provided to CCL by no later than 2/16/2024
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 7 of 12


Document Has Been Signed on 02/08/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that trash bins in residents rooms are not covered. Trash bin in resident room (R2) contained soiled brief for at least 2 days, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL pictures of trash bins fitted with appropriate lids by POC due date.
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that the drywall/sheet rock is missing from around shower spigot and pipe(s) exposed in resident's shower (R3) in room #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL pictures of repaired shower spigot so that pipes are not exposed and the shower spigot works properly. Facility to submit pictures by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 8 of 12


Document Has Been Signed on 02/08/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [2t] staff (S1) did not have health screen, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL health screen with clear TB for S1 by POC due date,
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in [2] out of [2 ]staff (S1 and S2) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
1
2
3
4
Facility to submit proof of training to CCL for S1 and S2 by POC due date. Training log must include name of course, hours completed, date completed, and trainer's name.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 9 of 12


Document Has Been Signed on 02/08/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(9)
General Food Service Requirements
(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that opened food items in refrigerator were not covered or labeled including a cake, half of a tomato, bowl of red substance, and a cup of brown liquid, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
1
2
3
4
Facility to conduct staff training on how to properly store opened food items. Facility to submit trainng log and materials used to administer training by POC due date.
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onLPA and Licensee observation, the licensee did not comply with the section cited above in that a bowl of cooked pasta left out overnight and during the day previous at room temperature, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
1
2
3
4
Facility to conduct staff training on how to properly store cooked food items. Facility to submit trainng log and materials used to administer training by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 10 of 12


Document Has Been Signed on 02/08/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation and Licensee record review, the licensee did not comply with the section cited above in that facility has not conducted quarterly disaster drill since 2020, as documented in disaster drill paperwork. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
1
2
3
4
Facility to conduct a drill for each shift and submit drill log to CCL by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [3] residents. Resident R1 has a physician report dated 2022 but nothing current which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/01/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL a current LIC602 for R1 by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 11 of 12


Document Has Been Signed on 02/08/2024 05:20 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 496800803

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in [1] out of [3] residents. Resident R1 did not have a current appraisal on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
1
2
3
4
Facility to submit to CCL a current Appraisal Needs and Services plan for R1 by POC due date. Appraisal shall be signed by all required parties.
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and Licensee observation, the licensee did not comply with the section cited above in that kitchen drawer containing sharp knives not locked, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
1
2
3
4
Facility to conduct staff training on how to properly store sharp knives and other items that could danger the residents by POC due date. Training log to be submitted to CCL by POC due date as well.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christi CoppoTELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:
DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024
LIC809 (FAS) - (06/04)
Page: 12 of 12