496800803-2-14-2025-21-AS-CCOO-DDW2LP-20250214162948

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 02/14/2025
Date Signed: 02/14/2025 04:30:24 PM

Document Has Been Signed on 02/14/2025 04:30 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 HOME		FACILITY NUMBER:	496800803
ADMINISTRATOR/ DIRECTOR:	LUNINGNING ALICDAN		FACILITY TYPE:	740
ADDRESS:	1923 FALLEN LEAF DR.		TELEPHONE:	(707) 545-1160
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95405
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	02/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:12 AM
MET WITH:	Luningning Alicdan		TIME VISIT/ INSPECTION COMPLETED:	04:45 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	Licensing Program Analysts (LPAs) Christi Coppo and Elias Magdaleno arrived unannounced to conduct a required Annual inspection and was greeted by licensee Luningning Alicdan. At approximately 9:30am LPAs and licensee toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPAs observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered. Garage cabinet containing cleaning supplies was unlocked, LPAs discussed with licensee cabinet must remain locked at all times. Kitchen drawer with sharp knives locked. All bedrooms were equipped with lighting, night stand, and chest of drawers. Extra hygiene products and linens were available. LPAs observed resident room 2 had commode full of waste and urine, with very strong odor filling the room. LPAs observed resident room 4 to have strong odor from urine as well. LPAs discussed with licensee importance of keeping facility and residents free from odors of incontinence (deficiency cited see 809D). Hallway floor in front of water heater closet outside of main hall bath has water damage. Per licensee, water damage caused by leaking water heater that was recently replaced. LPAs and licensee observed the laminate flooring was uneven as a result of damage and bowed inward under weight (deficiency cited see 809D). Resident bathroom had required bath mat and grab bar. Water temperature in sinks accessible to residents in care measured at 119.3 degrees F in hall bath and 117.6 degrees F in room 1A/1B which are within the allowable range of 105 to 120 degrees F. Fire extinguishers were last inspected 5/31/2024. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Facility’s last quarterly disaster drill was conducted 12/5/24. Facility has a backup generator for use during a power outage. Continued on 809C...

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Christi Coppo	TELEPHONE: (707) 588-5054
	DATE: 02/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

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 4

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: 02/14/2025

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...

At approximately 11:30am LPAs conducted review of five (5) staff records. Three (3) of five (5) staff (S1, S2, S3) did not have First Aid (deficiency cited see 809D). Two (2) of five (5) staff (S2, S3) were not associated with facility. However, licensee has previously discussed with LPA issue they are encountering with Guardian and being locked out/not able to access their account. LPA previously advised licensee that when they experience a pinch with Guardian to notify LPA and send LPA form LIC9182 so that LPA can associate the staff member to the facility. Licensee agrees and will immediately send LIC9182 to associate S1 and S2. Both S1 and S2 had fingerprint clearance and proof of clearance on file.

At approximately 1:10pm LPAs conducted a review of six (6) resident records. No deficiencies.

At approximately 3:00pm LPAs and licensee conducted a spot check of medication and medication records. Medication is centrally stored in a locked cabinet. No deficiencies.

Luningning Alicdan Administrator Certificate 7002894740 expired 10/10/2023, LPAs verified licensee is in pending renewal stauts. 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
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 Caregiver. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Caregiver and a copy of this report was given.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 02/14/2025 04:30 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: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87411(c)(1)

Personnel Requirements - General

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation and record review, the licensee did not comply with the section cited above in that three (3) of five (5) staff (S1, S2, S3) did not have First Aid which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/17/2025
	Plan of Correction
1 2 3 4	Facility to submit plan to have staff complete First Aid. Facility to submit proof of First Aid certificates for S1,S2,S3 by no later then 3/7/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Christi Coppo	TELEPHONE: (707) 588-5054
	DATE: 02/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 02/14/2025 04:30 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: 02/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) 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
1 2 3 4	Based on LPAs and licensee observations, the licensee did not comply with the section cited above in that Hallway floor outside of hall bathroom has water damages causing expansion of laminate flooring resulting in uneven walking surface. Floor bows inward under weight, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/07/2025
	Plan of Correction
1 2 3 4	Facility to submit video of repaired flooring bearing weight without bowing by Plan of Correction due date.

Type B

Section Cited

CCR

87625(b)(3)

Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs and licensee observations, the licensee did not comply with the section cited above in that resident room 2 had commode full of waste and urine, with very strong odor filling the room. LPAs observed resident room 4 to have strong odor from urine as well which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/21/2025
	Plan of Correction
1 2 3 4	Facility to submit LIC9098 self certifying that all waste and urine will be discarded promptly and properly. Additionally licensee will self certify that facility will remain free of incontince odors by Plan of Correction 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.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Christi Coppo	TELEPHONE: (707) 588-5054
	DATE: 02/14/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2025

LIC809 (FAS) - (06/04)

Page: 4 of 4