496802052-6-19-2024-21-AS-CFES-D6DW5P-20240619165930

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 06/19/2024
Date Signed: 06/19/2024 04:59:49 PM

Document Has Been Signed on 06/19/2024 04:59 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 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: 9	DATE:	06/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:			TIME COMPLETED:	05:15 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	At approximately 8:25AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a 1-Year Required Visit and met with Staff Member, Andrea Dela Chica. Licensee/Administrator, Bot Alicdan, arrived during visit at approximately 9:00AM. Facility serves older adults and has a plan of operation for dementia care and programming on file. Facility has an approved fire clearance and total capacity for 13 residents of which 11 residents can be non-ambulatory, and 2 residents can be bedridden. Facility has an approved hospice waiver for 3 individuals. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were 9 Residents in care and 2 staff members on-site. At approximately 8:45AM, LPA reviewed the Facility's Staff Roster and found that all staff on-site were not associated to the facility per regulation. LPA confirmed on the Guardian website that the two staff members were background cleared but not were associated to the facility as required (deficiency cited, see LIC809D and LIC421BG, regulation 87553(e)). At approximately 9:25AM, LPA conducted a walk-though of the facility with Licensee. Per Facility sketch, facility is a one story building with 11 bedrooms, 11 bathrooms, and common spaces. LPA observed the following: facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility has an Infection Control plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Mattress pads were in place or available for Resident use. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. Hot water temperatures for 7 of 13 facility sinks were found to be out of compliance with Title 22 Regulations of 105 to 120 degrees Fahrenheit, measuring between 120.5F to 126.8F (deficiency cited, see LIC809D, regulation 87303(e)(2)). During walkthrough, LPA observed the following toxins, hazards, and medications to be accessible: unlocked knife drawer in the kitchen, Disinfectant cleaner in the bathroom, bed bug repellent in a cabinet located in the dining room. LPA also observed blood sugar monitors and sharps located in the facility's dining room drawer, and 3 bottles of cough syrup, 1 bottle of Pepto Bismol and 1 bottle of Tums in a resident's room. Review of resident's LIC602 stated that resident has a dementia diagnosis and is unable to manage their own medications (deficiencies cited, see LIC809D, regulation 87705(f)(2)). Licensee immediately collected all toxins and ensured that they were locked and inaccessible. Licensee also removed medications from resident's room. Continued on LIC809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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 II RCFE	FACILITY NUMBER: 496802052
	VISIT DATE: 06/19/2024

NARRATIVE

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Continued from LIC809
LPA observed that a window in a resident's room needed replacing. Per LPA observation, the window was being propped up by a fake piece of fruit. Further observation showed that the window was loose and could not withstand its weight when opened (see technical violation, LIC9102, regulation 87303(a)). LPA observed that some resident rooms had garbage cans with lids, while other resident rooms did not have garbage cans with lids (see technical violation, LIC9102, regulation 87303(f)(3)). LPA also observed prepoured PM medications in a locked cabinet. Per conversation with Licensee and Staff Member, the PM medications were poured this morning. Review of visit conducted on 06/01/2023 indicated that the facility was issued a technical advisory and therefore was aware that pre-pouring medication was against regulation (deficiency cited, see LIC809D, regulation 87465(h)(5)).
Facility's fire extinguishers were last inspected May 2024. Smoke and carbon monoxide detectors were tested and operational. Facility's last emergency/disaster drill was conducted May 2024.

At approximately 11:30AM, LPA reviewed staff files, resident files, and resident medications. Review of staff files showed that Staff Member 3 (S3) was missing their Health Screening (LIC503) report and proof of negative TB test. 3 of 4 staff members did not have annual 2023 training completed (deficiencies cited, see LIC809D, Regulation 87411(f), and Health and Safety Code, 1569.625(b)(2)). Per discussion with Licensee, all staff have been signed up for online training. 3 of 4 staff files had current First Aid and CPR certification. Per discussion with Staff Member 1 (S1), their certification card is at home but they always work with Staff Member 2 (S2) at the facility. Review of S2's file indicated that they had current first aid/cpr certification (see technical violation, LIC9102, 1569.618(c)(3)). Review of resident files showed that 3 of 9 resident files were missing their reappraisal assessments. Of the 9 residents, 2 residents with a diagnosis of dementia were missing updated annual Physician Reports. 9 of 9 resident files were missing their Needs and Services Plan. 1 of 9 files was missing their Pre-Appraisal Assessment (deficiencies cited, see LIC809D, regulation 87705(c)(5), regulation 87467(a)(2), and regulation 87467(a)). Licensee understands that Pre-Appraisal assessments should be conducted prior to residents moving into the facility. Licensee also understands that assessments and appraisals should be conducted annually for residents with a dementia diagnosis. LPA reviewed 4 of 9 resident medications. During review, LPA observed that some medications were not centrally stored as required. LPA observed that some medications were either not logged or had incorrect dates logged (deficiency cited, see LIC809D, regulation 87465(h)(4)).

Administrator Certificate for Luningning (Bot) Alicdan (6010428470) expired 10/18/2023. Review of Guardian's website showed that Licensee/Administrator's name is not on the pending list or active list. Per Guardian website, renewal applications are being reviewed for the week of 11/06/2023. Licensee informed LPA that they submitted payment for their renewal in 2023.

Continued on LIC809C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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 II RCFE	FACILITY NUMBER: 496802052
	VISIT DATE: 06/19/2024

NARRATIVE

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Continued from LIC809C

LPA requested the following documentation to update the facility file:

Designation of Facility Responsibility (LIC 308)
Emergency Disaster Plan (LIC 610D)
Updated Personnel Report (LIC 500)
Register of Clients/Residents (LIC 9020)
Updated Liability Insurance
Active and Current Administrator Certificate

Facility Documents to be submitted to Community Care Licensing (CCL) by due date of 07/19/2024.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An Immediate Civil Penalty in the total amount of $200 is being assessed for a lack of staff association as required for S1 and S2 (See LIC421BG).**

Exit interview conducted. Copy of report, LIC-809D (Deficiency Page), LIC9102 (Technical Advisory/Violation), LIC421BG (Civil Penalties for Caregiver Background Check) Plan of Corrections, and Appeal Rights discussed and provided to Licensee/Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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 II RCFE	FACILITY NUMBER: 496802052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the Licensee did not comply with the section cited above. 1 of 4 staff members were missing proof of their health screening report and proof of negative TB. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee to submit health screening report and proof of negative TB test by POC due date of 06/20/2024.

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

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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 II RCFE	FACILITY NUMBER: 496802052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed, the Licensee did not comply with the section cited above. 3 of 4 staff members were missing proof of their annual 2023 training. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee to submit written plan outlining how they will ensure annual training is completed timely by POC due date of 06/20/2024. Licensee to submit proof of online training for all staff by POC due date of 06/30/2024.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, the Licensee did not comply with the section cited above. LPA observed the following toxins, hazards, and medications to be accessible: unlocked knife drawer, Disinfectant cleaner, bed bug repellent, blood sugar monitors and sharps, 3 bottles of cough syrup, 1 bottle of Pepto Bismol and 1 bottle of Tums. This poses an immediate health, safety or personal rights risk to residents in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	Licensee to submit self certification that training for Regulation 87705(f)(2) will be conducted for all staff by POC due date of 06/20/2024. Training to review items that are inaccessible to residents in care. Licensee to conduct Inservice Training that includes the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 06/30/2024.

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

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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 II RCFE	FACILITY NUMBER: 496802052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, the Licensee did not comply with the section cited above. 2 of 2 staff members were found to be background cleared but not associated to the facility as required. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 06/30/2024
	Plan of Correction
1 2 3 4	Licensee to ensure that all staff members are associated to the facility per regulation. Licensee to submit proof of Guardian Roster with associated staff members by POC due date of 06/30/2024.

Type B

Section Cited

CCR

87465(h)(4)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, the Licensee did not comply with the section cited above. 4 of 9 resident medications reviewed were not centrally stored as required. LPA observed that some medications were not logged or incorrectly documented. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 06/30/2024
	Plan of Correction
1 2 3 4	Licensee to conduct in-service training for all staff to review how to document centrally store medications. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 06/30/2024.

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

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

Page: 7 of 12

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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 II RCFE	FACILITY NUMBER: 496802052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, the Licensee did not comply with the section cited above. LPA observed pre-poured medications located in a locked cabinet. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 06/30/2024
	Plan of Correction
1 2 3 4	Licensee to conduct in-service training for all staff reviewing that pre-poured medications are not allowed. Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 06/30/2024.

Type B

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, the Licensee did not comply with the section cited above. 1 of 9 residents did not have a completed Pre-Appraisal as required. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 06/30/2024
	Plan of Correction
1 2 3 4	Licensee to complete pre-appraisal for resident and submit a copy to Community Care Licensing (CCL) by POC due date of 06/30/2024.

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

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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 II RCFE	FACILITY NUMBER: 496802052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, the Licensee did not comply with the section cited above. 2 of 9 residents did not have an updated Physician's Report as required. These two residents had a dementia diagnosis. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 06/30/2024
	Plan of Correction
1 2 3 4	Licensee to schedule appointments for both residents so they can have a new assessment completed. Licensee to provide an update on their statuses by POC due date of 06/30/2024. Copies of updated physician reports to be submitted Community Care Licensing (CCL) once received.

Type B

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations made, the Licensee did not comply with the section cited above. 7 of 13 facility sinks were found to be out of Title 22 regulations of 105F to 120F measuring between 120.5F and 126.8F. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 06/30/2024
	Plan of Correction
1 2 3 4	Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks starting on 06/20/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 06/30/2024.

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

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

Page: 9 of 12

Document Has Been Signed on 06/19/2024 04:59 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 II RCFE	FACILITY NUMBER: 496802052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87467(a)

87467 Resident Participation in Decisionmaking (a) Prior to, or within two weeks of the resident’s admission, the licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident’s preferences regarding the services provided at the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the Licensee did not comply with the section cited above. 9 of 9 resident files did not have a needs and services plan. This poses a potential health, safety or personal rights risk to residents in care.
	POC Due Date: 06/30/2024
	Plan of Correction
1 2 3 4	Licensee to complete all needs and services plans and submit copies to CCL by POC due date of 06/30/2024.

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.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC809 (FAS) - (06/04)

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