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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 05/16/2024
Date Signed: 05/16/2024 03:13:37 PM

Document Has Been Signed on 05/16/2024 03:13 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/
DIRECTOR:		LUNINGNING ALICDANFACILITY TYPE:
740
ADDRESS:1923 FALLEN LEAF DR.TELEPHONE:
(707) 545-1160
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Edward Alicdan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
03:28 PM
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
At approximately 11:15am Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a Case Management and was greeted by caregiver. Licensee Edward Alicdan arrived later. Facility currently has 6 residents in care, one of which is on hospice, which is allowable per the facility's Hospice Waiver.

Upon arrival at facility LPA and caregiver observed unlocked medication cart in living room (deficiency cited and civil penalty issued for repeat violation within 12 months, see 809D and LIC421FC). Upon arrival LPA and caregiver observed unlocked hallway closet containing toxins (deficiency cited and civil penalty issued for repeat violation within 12 months, see 809D and LIC421FC). LPA reviewed Physician's Report for new resident R1 and found it not to be signed by a physician. Per licensee, the unsigned Physician's report is the only one retained by facility for resident (deficiency cited, see 809D).

On 3/29/2024 Licensee came to the SRRO for an informal meeting to discuss recent citations and corresponding plans of corrections not fulfilled. Licensee expressed interest in participating in CCL’s Technical Support System (TSP) in order to gain compliance with regulations for which they received deficiency citations.

On 4/4/2024 CCL’s Technical Support Program analyst reached out to Licensee to confirm interest in participation, no response was received. On 4/22/2024 LPA received notification from Technical Support Program analyst advising they have not received a response from licensee to date. TSP analyst advised the licensee that signed participation agreement must be received by 4/25/24. On 5/1/2024 the Technical Support Program analyst sent a closure letter to the licensee, closing the referral due to lack of response by the licensee. Citations issued on 2/8/2024 were cleared during office meeting because Licensee agreed to TSP. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies issued on 2/8/2024 are being re-cited (deficiencies cited, see 809D).

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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 8
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: 05/16/2024
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
Continued from 809...

Per agreement during office meeting with licensee on 3/29/2024, licensee was to review and submit their Plan of Operation to ensure facility's compliance with Title 22 regulations going forward. As of today, 5/16/2024 licensee has not provided CCL with review of Plan of Operation (deficiency cited, see 809D). 87208

Per agreement during office meeting with licensee on 3/29/2024, licensee was to send over Health Screen, Training, and 1st Aid/CPR for new employee at Fallen Leaf Dr. As of today, CCL has not received the required documentation (deficiency cited, see 809D).

CCL review of facility's training materials provided by Licensee do not meet regulation. Licensee to submit updated training materials that meet regulation by 5/23/2024. Once training materials are approved by CCL, licensee to conduct required training in order to fulfill respective plan of corrections for deficiencies cited and re-cited today.

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 deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An immediate civil penalty in the total amount of $250 has been issued for repeat violation of regulation 87465(h)(2) and an immediate civil penalty in the total amount of $250 has been issued for repeat violation of regulation 87705(f)(2). See LIC421FC**

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

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 05/16/2024 03:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/16/2024 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2024
Section Cited

1
2
3
4
5
6
7
87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year... This requirement was not met by licensee as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation the Physician's Report for new resident R1 was not signed by a physician. Per LPA interview with licensee, the unsigned Physician's report is the only one retained by facility for R1, which poses/posed a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
05/30/2024
Section Cited

1
2
3
4
5
6
7
87208 Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation.

This requirement was not met by licensee as evidenced by:
8
9
10
11
12
13
14
Per agreement during office meeting with licensee on 3/29/2024, licensee was to review and submit facility's Plan of Operation. Licensee has not submitted Plan of Operation to CCL, which poses a potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 05/16/2024 03:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/16/2024 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2024
Section Cited

1
2
3
4
5
6
7
87465 (h) The following requirements shall apply to medications...centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees....This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation the licensee did not comply with the section cited above in that med cart in living room was unlocked which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
name of trainer, name of course, staff attendees and hours completed. A civil penalty in the amount of $250 is being assessed for repeat violation within 12 months.
Type A
05/17/2024
Section Cited

1
2
3
4
5
6
7
87705 (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication... cleaning supplies and disinfectants. This requirement was not met by licensee as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation, the licensee did not comply with the section cited above in that the hallway closet containing toxins was unlocked and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
name of trainer, name of course, staff attendees and hours completed. A civil penalty in the amount of $250 is being assessed for repeat violation within 12 months.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 05/16/2024 03:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/16/2024 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited

1
2
3
4
5
6
7
87465 (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:
8
9
10
11
12
13
14
Based on: LPA observation, the licensee did not comply with the section cited above as unlocked drawer in kitchen contained pre-poured medication. Due to Licensee’s failure to respond to and work with CCL's TSP to correct identified concerns, deficiencies are being re-cited.
8
9
10
11
12
13
14
staff attendees, and hours completed.
Type B
06/06/2024
Section Cited

1
2
3
4
5
6
7
87303(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:
8
9
10
11
12
13
14
Based on LPA observation, the licensee did not comply with the section cited above in that syringe for insulin was found accessible, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.
8
9
10
11
12
13
14
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 05/16/2024 03:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/16/2024 at 02:16 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited

1
2
3
4
5
6
7
87412 (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...This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA record review, the licensee did not comply with the section cited above in that staff (S1) did not have health screen, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.
8
9
10
11
12
13
14
Type B
06/06/2024
Section Cited

1
2
3
4
5
6
7
HSC 1569.625 (2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...

This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA record review, the licensee did not comply with the section cited above in that training records for staff not available, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.
8
9
10
11
12
13
14
Training log to include: name of trainer, name of course, staff attendees and hours completed.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 05/16/2024 03:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/16/2024 at 02:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited

1
2
3
4
5
6
7
87555(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:
8
9
10
11
12
13
14
Based on LPA observation, the licensee did not comply with the section cited above in that opened food items in refrigerator were not covered or labeled, which poses a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

8
9
10
11
12
13
14
Training log to include: name of trainer, name of course, staff attendees and hours completed.
Type B
06/06/2024
Section Cited

1
2
3
4
5
6
7
87555(b) The following food service requirements shall apply: (23) All readily perishable foods...capable of supporting... growth of micro-organisms...shall be stored in covered containers at appropriate temperatures. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA observation, the licensee did not comply with the section cited above in that a bowl of cooked pasta left out overnight, which posed a potential health, safety or personal rights risk to persons in care. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.

8
9
10
11
12
13
14
Training log to include: name of trainer, name of course, staff attendees and hours completed.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8
Document Has Been Signed on 05/16/2024 03:13 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/16/2024 at 02:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited

1
2
3
4
5
6
7
87705 (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:
8
9
10
11
12
13
14
Based on LPA 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. Due to Licensee’s failure to respond to and work with TSP to correct identified concerns, deficiencies are being re-cited.
8
9
10
11
12
13
14
by no later than 6/6/2024. Training log to include: name of trainer, name of course, staff attendees and hours completed.

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 05/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024


LIC809 (FAS) - (06/04)
Page: 8 of 8