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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 05/31/2024
Date Signed: 05/31/2024 02:57:30 PM

Document Has Been Signed on 05/31/2024 02:57 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: DATE:
05/31/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:13 PM
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Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Administrator Luningning Alicdan.

On 5/16/2024 LPA Coppo conducted a Case Management to address Licensee’s failure to respond to and work with CCL’s Technical Support System (TSP) in order to gain compliance with regulations for which they received deficiency citations on 2/8/2024. Deficiencies issued on 2/8/2024 were re-cited.

Upon LPA arrival at facility on 5/16/2024 LPA and caregiver observed unlocked medication cart in living room and also observed unlocked hallway closet containing toxins. Two civil penalties were issued for repeat citations of these deficiencies: 87465(h)(2) and 87705(f)(2), respectively. The CCL report issued on 5/16/2024 reiterated CCL’s finding that facility's training materials provided by Licensee do not meet regulation. Licensee was to submit updated training materials that meet regulation by 5/23/2024. Additionally, once the submitted training materials were approved by CCL, licensee was to conduct required training in order to fulfill respective plan of corrections for deficiencies cited and re-cited on 5/16/2024.

As of today, 5/31/2024 CCL has not received from facility any training materials submitted for approval. However, licensee submitted to CCL on 5/28/2024 LIC9098s self-certifying that training was conducted by licensee on May 18, 2024 and May 19, 2024, respectively, to fulfill plan of corrections for deficiencies: 87465(h)(2) and 87705(f)(2). The plan of correction for deficiencies 87465(h)(2) and 87705(f)(2) stated “Facility to submit to CCL a plan to train staff to properly store medications. Plan due by plan of correction due date. Once facility training materials are approved by CCL, staff training to be completed and training log provided to CCL by no later than 5/31/2024. Training log to include name of trainer, name of course, staff attendees and hours completed.” Due to facility not having approved training materials to conduct training, the plans of correction for deficiencies 87465(h)(2) and 87705(f)(2 have not been fulfilled. Civil penalties are being assessed in the amount of $100 per day for failure to correct deficiencies 87465(h)(2) and 87705(f)(2).

Continued on 809C...
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
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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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: 05/31/2024
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Per CCL and licensee agreement during office meeting 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 5/16/2024 licensee had not provided CCL with Plan of Operation and the deficiency was cited on 5/16/2024. On 5/28/2024 CCL received from licensee an outline of their plan of operation, not the pertinent portion that addresses training. However, the plan of correction issued by LPA did not specify that the portion of the plan of operation being requested specifically pertains to training. Therefore, LPA is giving an extension for deficiency 87208(a) until 6/7/2024.

LPA and Licensee discussed choosing a vendor for training from the vendor list that LPA emailed to licensee on 5/7/2024, as they are already approved and therefore licensee will not need to submit training materials for CCL to approve. Should licensee chose an approved vendor, licensee will notify LPA of selection choice no later than 6/10/2024. Should licensee not choose an already approved vendor, licensee will need to submit training materials to CCL for approval no later than 6/10/2024. Once training materials are either approved or an approved vendor is chosen, licensee to complete trainings in order to fulfill plans of correction for deficiencies re-cited on 5/16/2024. Licensee will have employees complete the trainings required in order to fulfill plans of correction for deficiencies re-cited on 5/16/2024 by 6/24/2024.

**Civil penalties assessed in the amount of $100 per day for failure to correct deficiencies 87465(h)(2) and 87705(f)(2), respectively (see LIC 421FC).**

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

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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