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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:45:52 AM

Document Has Been Signed on 07/31/2024 11:45 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/
DIRECTOR:		LUNINGNING ALICDANFACILITY TYPE:
740
ADDRESS:1923 FALLEN LEAF DR.TELEPHONE:
(707) 545-1160
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: DATE:
07/31/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:57 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Regional Manager, Carla Nuti-Martinez, Licensing Program Manager Victoria Bertozzi, and Licensing Program Analyst Christi Coppo met with Licensee, Bot Alicdan to conduct a Non-Compliance Conference.

Parties discussed multiple areas of concern including but not limited to the following:
  • Administrator Duties and Plan of Operation
  • Staff Training
  • Resident and staff records
  • Resident Care and Personal Rights
  • Insufficient Staffing
  • Failure to clear deficiencies timely
  • Medication Management
  • Failure to follow through with TSP

Licensee to ensure the following:
  • Follow through with responding to and participating with the Technical Support Program
  • Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication.
  • Ensuring personal rights of residents in care and ensuring resident needs are met.


Licensee agrees to be placed on a non-compliance plan for a period of two years.

Licensee has agreed to Technical Support Provider (TSP) service. CCL will submit a TSP referral

No deficiencies cited.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2024
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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