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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:00:38 PM

Document Has Been Signed on 06/01/2023 02:00 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 RCFEFACILITY NUMBER:
496802052
ADMINISTRATOR:ALICDAN, LUNINGNINGFACILITY TYPE:
740
ADDRESS:3101 BRUSH CREEK ROADTELEPHONE:
(707) 537-0399
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 13CENSUS: 10DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Licensee/Administrator, Luninging (Bot) AlicdanTIME COMPLETED:
02:10 PM
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Licensing Program Analyst Bertozzi arrived unannounced to conduct an Annual Required Inspection and met with Licensee/Administrator, Luninging (Bot) Alicdan. There were three care givers on duty to provide care and supervision for ten residents. Facility currently has three residents on hospice which is allowable per the facility's Hospice Waiver. Facility also has a waiver to have a secure perimeter.

LPA initiated a tour of the facility around 9:40 am and made the following observations: Facility was a comfortable temperature with thermostat reading at 71 degrees F. Passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in sink accessible to residents in care measured at 109 degrees F which is within allowable range of 105 to 120 degrees F. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinet containing medications was locked. Kitchen cabinet containing cleaning supplies was locked. Facility has at least two days of perishable and one week of non-perishable foods.

Fire extinguisher was last inspected June 2022. Carbon Monoxide detectors were tested and operational. Facility has a fire alarm system that is maintained by a vendor. Facility was recently inspected by the local fire department and no issues were noted regarding fire alarms.

Three staff files and ten resident files were reviewed. Staff have required First Aid and CPR certificates. Administrator Certificate for Administrator, Luninging Alicdan 6010428740 expires 10/18/2023. Medications and medication records were reviewed. Training records were reviewed. Required postings were observed. LPA confirmed that facility has valid Liability Insurance

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/01/2023 02:00 PM - It Cannot Be Edited


Created By: Victoria Bertozzi On 06/01/2023 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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
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Based on record review, the licensee did not comply with the section cited above in two out of two staff not having documented annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to update the training logs to reflect all required trainings and provide the required annual training to their existing staff and submit proof of training to CCL no later than POC due date, 6/30/2023.
Type B
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of two staff not having documented annual training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/30/2023
Plan of Correction
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Licensee agrees to submit proof of medication training to CCL no later than POC due date, 6/30/2023.
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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


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: 06/01/2023
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Continued from LIC809

Licensee provided LPA a copy of their liability insurance and LIC 308 (Designation of Responsibility) forms.

Licensee/Administrator to submit updates of the following documents by 7/01/2023:



LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (If changes)
Infection Control Plan (If changes)

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
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
LIC809 (FAS) - (06/04)
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