496802052-6-1-2023-21-AS-CMAZ-CSMM4C-20230609091627

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802052
Report Date: 06/01/2023
Date Signed: 06/01/2023 01:59:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/24/2023 and conducted by Evaluator Victoria Bertozzi

COMPLAINT CONTROL NUMBER: 21-AS-20230424134753

FACILITY NAME:	BETSY'S II RCFE		FACILITY NUMBER:	496802052
ADMINISTRATOR:	ALICDAN, LUNINGNING		FACILITY TYPE:	740
ADDRESS:	3101 BRUSH CREEK ROAD		TELEPHONE:	(707) 537-0399
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY:	13	CENSUS: 10	DATE:	06/01/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee/Administrator, Luninging (Bot) Alicdan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Personal Rights
Licensee refused to allow resident to return to facility from the hospital

INVESTIGATION FINDINGS:

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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Licensee/Administrator, Luninging (Bot) Alicdan.

Personal Rights – Complaint alleges that staff was observed yelling and cursing in front of a resident and that a staff told the resident that they were going to “dump” them at the emergency room. Staff denied yelling in front of resident. A witness reported that staff appeared agitated but denied observing staff curse or yell. Witness reported that resident felt uncomfortable but resident denied feeling unsafe with staff.

Licensee refused to allow resident to return to facility from the hospital – Complaint alleges that resident was discharged from the hospital and was in the facility for one day before being returned to the emergency room and dropped off.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230424134753

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II RCFE	FACILITY NUMBER: 496802052
	VISIT DATE: 06/01/2023

NARRATIVE

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Continued from LIC9099

Per interviews, resident came to the facility but was missing their medication so returned to the emergency room. Some interviews report that the resident insisted on returning to the hospital while another reported that the Licensee returned the resident with no notice. Staff did not stay with resident while they were in the hospital and the resident did not return to the facility once discharged. Per file review, an Admission Agreement was not completed. Based on evidence obtained during investigation, it was not clear if facility refused to bring resident back to the facility or if resident refused to return to the facility.

A finding that complaint allegations Personal Rights and Licensee refused to allow resident to return to facility from the hospital was unsubstantiated meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegations occurred.

No deficiencies cited.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023

LIC9099 (FAS) - (06/04)

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