496800803-2-14-2025-21-AS-CCOO-DDW2PX-20250214163505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 02/14/2025
Date Signed: 02/14/2025 04:35:14 PM

Document Has Been Signed on 02/14/2025 04:35 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:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:04 AM
MET WITH:	Luningning Alicdan		TIME VISIT/ INSPECTION COMPLETED:	04:49 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 Non-compliance and was greeted by Administrator Luningning Alicdan. On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as: · 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 was 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. 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)

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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: 02/14/2025

NARRATIVE

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Continued from 809...

Today, LPAs conducted an annual inspection in conjunction with the Non-Compliance inspection. Licensee found to be in compliance as pertains to Administrator duties and plan of operation and pre-pouring of medication. Licensee has followed through with TSP.

Licensee found out of compliance pertaining to personal rights of residents in that LPAs observed resident room 2 had commode full of waste and urine, with very strong odor filling the room. Staff (S3) advised LPAs that they will wait until after resident (R2) is finished with breakfast. R2 was eating breakfast in their room where commode full of waste and urine was also present. LPAs advised that waste and urine should be immediately discarded as soon as possible, letting it sit for extended periods of time is not conducive to a healthy environment; additionally, the facility must be kept free of incontinence odors. LPAs observed resident room 4 to have strong odor from urine as well. LPAs discussed with licensee and again discussed the importance of keeping facility and residents free from odors of incontinence, deficiency cited on Annual inspection. LPAs found two [2] staff (S2 and S3) not associated to the 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.

Licensee found out of compliance with staff training as three [3] out of five [5] staff (S1, S2, and S3) did not have First Aid training on file, deficiency cited on Annual inspection.

Licensee has not had any outstanding deficiencies to clear in a timely manner, so licensee found to be in compliance with clearing deficiencies timely. LPAs reviewed LIC500 and find that licensee is in compliance pertaining to staffing. Licensee in compliance with resident records with the following exception: Resident (R1) has a physician’s report dated 1/16/24 with a DX of dementia; however, resident is on hospice. LPAs reviewed hospice care notes which are current as of 2/12/25. LPAs discussed with Admin getting a current hospice care plan with current dates from hospice company.

All deficiencies referenced cited on annual inspection (see 809Ds). Exit interview conducted with licensee 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)

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