496802052-10-3-2024-21-AS-VBEI-DA2S3G-20241014133106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496802052
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:29:43 AM

Substantiated

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
09/26/2024 and conducted by Evaluator Christi Coppo

COMPLAINT CONTROL NUMBER: 21-AS-20240926120125

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:	DATE:	10/03/2024
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Luningning Alicdan		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Licensee is not addressing pests at facility

INVESTIGATION FINDINGS:

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At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegation.

Complaint alleges licensee is not addressing pests at facility. LPA spoke with licensee and licensee said she knows about the bed bugs and that she has someone coming tomorrow to take care of them. LPA asked licensee about alleged on-going bed bug issue at facility. Licensee said she does not know why they keep having an issue, she has Terminex spray every quarter. Previously, the pest company wanted to tent the home for 3 days and licensee explained she could not relocate all the residents for that amount of time. LPA and licensee discussed that only heat treatment will kill bed bugs. Licensee advised she understands that now and is having heat treatment completed. Licensee informed LPA that during the bed bug treatment she will have the residents out on the patio for the two hours it will take.

Continued on 9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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-20240926120125

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: 10/03/2024

NARRATIVE

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Continued from 9099...

Based on interview with licensee, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D.
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 licensee. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. 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: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240926120125

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/03/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/10/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Facility to submit work order and paid invoice for bed bug treatment by professional company by plan of correction due date.
	8 9 10 11 12 13 14	This requirement was not met by license as evidenced by: Facility on-going issue of bed bugs present at facility is known by licensee, which poses an immediate health, safety, and personal rights risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Christi Coppo	TELEPHONE: (707) 588-5054
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC9099 (FAS) - (06/04)

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