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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 04/24/2025
Date Signed: 04/24/2025 05:24:23 PM

Document Has Been Signed on 04/24/2025 05:24 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/
DIRECTOR:		ALICDAN, LUNINGNINGFACILITY TYPE:
740
ADDRESS:3101 BRUSH CREEK ROADTELEPHONE:
(707) 537-0399
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 13CENSUS: 13DATE:
04/24/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Luningning Alicdan, AdminTIME VISIT/
INSPECTION COMPLETED:
05:38 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Christi Coppo and Robert Frank 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 809-C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 11
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/24/2025
NARRATIVE
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Continued from 809...

Today, LPAs conducted the Non-Compliance inspection. Licensee found to be in compliance as pertains to responding to and participating with the Technical Support Program.

LPAs reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records, and pre-pouring of medication. Staff members S1, S2 and S3 did not required hours of training on file (deficiency cited, see 809D). S3, S4, and S5 did not have Health Screens on file (deficiency cited, see 809D).R1, R2, R3, R4, and R5 all did not have current appraisals on file (deficiency cited, see 809D).

LPAs conducted interviews and made observations pertaining to Admin's ensuring of personal rights of residents in care and ensuring resident needs are met. Prescription and PRN medications were observed to be unsecured in the following rooms 10, 8, and 9. LPAs also observed there were unsecured medications and sharps (lancets), as well as sharps disposal container, in the cabinet next to the dining room table (deficiency cited, see 809D). LPAs observed prescription medication had its label partially removed in R3's room number four (4) (deficiency cited, see 809D).

LPAs observed golf ball sized bruised knot on R4's left hand side forehead. R4 reported that they fell and hit their head but that it doesn't hurt. Admin advised that R4's POA decided R4 did not need to go to the hospital. LPAs advised Admin that facility must call EMS and let them determine if the resident needs to have medical attention, if the resident then refuses that is their right but the EMS must be called first. LPAs also advised that an Incident Report must be submitted for any incident which threatens the welfare, safety or health of any resident, R3 reported to LPAs that two [2] times since New Year's Eve the Admin had to call 911 to help them with breathing issues. However, per LPAs' observation, no Incident report was submitted reporting the emergency services for R3. Admin could not produce an Incident report for either R3 or R4 (deficiency cited, see 809D)

LPAs observed an oxygen tank in storage closet that was not secured to the wall or in an oxygen cradle (deficiency cited, see 809(D). LPAs observed that the hot water was both below and above the Title 22 regulation of being between 105 and 120 degrees F in room seven (7) and one (1) (deficiency cited, see 809D).

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 11
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: 04/24/2025
NARRATIVE
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Continued from 809-C

LPAs observed door to laundry room from facility unlocked; LPAs observed unsecured cleaning products in metal cabinet found unlocked in laundry room (deficiency cited, see 809D). In the laundry room LPAs observed a large container of eggs on a shelf that were left unrefrigerated (deficiency cited, see 809D). LPAs observed an open can of cat food that was moldy in room three (3). LPA's observed an HVAC intake vent in the front hallway that was covered in dust/dirt and a grease like substance. LPAs observed many small unsealed or tied trash bags full of soiled incontinence briefs in laundry room with eggs (deficiency cited, see 809D). LPAs observed an extremely strong urine odor in room five (5) and odor in room two [2B] (deficiency cited, see 809D).

LPAs observed S6 to be providing care to residents. S6 has fingerprint clearance and is associates to the facility; however there is no file on premises for S6. Admin explained S6 is their family member and is now living here. LPAs advised that all staff providing care to residents must have training, Health Screen and TB clearance on file as well as First Aid/CPR.

Admin provided LIC500 to LPAs which indicated Admin is scheduled Monday-Friday 1pm-3pm and Monday-Friday 7pm-7am. LPAs advised that Admin duties must performed on business days within business hours such that they have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility.

Admin advised LPAs that they are very close to closing escrow with a buyer for the facility. LPAs advised residents will need a 60 day notice and it will need to be submitted to CCL as soon as issued. Admin to contact LPA for further instructions on required items for change of facility ownership.

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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with Administrator and a copy of this report was given..

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC809 (FAS) - (06/04)
Page: 5 of 11
Document Has Been Signed on 04/24/2025 05:24 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/24/2025 at 01:52 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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2025
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees... This requirement not met
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Licensee will submit LIC9098 to CCL self certifying that all medications wll be kept in a safe and locked place. Licensse will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times.
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by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that prescription and PRN medications were accessible to residents in rooms 10, 8, 9, and in dining and laundry room, which poses a potential health, safety or personal rights risk to persons in care.
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Type A
04/25/2025
Section Cited
HSC1569.625(b)(2)

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§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with
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Licensee to submit plan to conduct training for S1, S2, and S3 in the required number of hours required by regulation, based on staff members'' start dates, by plan of correction due date. Training reocrds to be submitted no later than 5/2/25.
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the section cited above in that S1, S2 and S3 did not required hours of training on file, which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
Page: 4 of 11
Document Has Been Signed on 04/24/2025 05:24 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/24/2025 at 02:31 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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2025
Section Cited
CCR
87618(b)(3)(E)

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87618 Oxygen Administration ...the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (E) Oxygen tanks that are not portable shall be secured in a stand or to the wall. This requirement not met by licensee as
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Admin immediately removed oxygen tank from storage closet and placed in a cradle in resident's room. Deficiency cleared.
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evidenced by: Based on LPA and Admin observation oxygen tank in storage closet not secured to wall or in cradle, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/01/2025
Section Cited
CCR87411(f)

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87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health...Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test...This requirement not met by licensee as evidenced by:
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Licnesee to submit pictures of or completed Health Screens for S3, S4, and S5, to CCL by plan of correction due date.
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Based on LPA and Admin observation, the licensee did not comply with the section cited above in that S3, S4, and S5 did not have Health Screens on file, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
Page: 6 of 11
Document Has Been Signed on 04/24/2025 05:24 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/24/2025 at 02:32 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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation
(a)The facility shall be clean, safe, sanitary and in good repair at all times...This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs
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Photos of cleaned vent to be submitted no later than 5/2/25.
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observed intake vent in front hallway covered in dust/dirt and a grease like substance, which poses an immeidate health, safety or personal rights risk to persons in care.
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Type A
04/25/2025
Section Cited
CCR87303(e)(2)

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87303 Maintenance and Operation (e)Water supplies and plumbing fixtures shall be maintained...
(2)Faucets used by residents...shall deliver hot water...of not less than 105 degree F and not more than 120 degree F. This requirement not met by licensee
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Facility to submit plan to record water temperature for 2 weeks showing water tempertaure within regulation by plan of correction due date. Two week water log to be submitted no later than 5/9/25. Log to be submitted with picture of thermotoer in running water with temperature visible.
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as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that
which poses an immeidate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
Page: 7 of 11
Document Has Been Signed on 04/24/2025 05:24 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/24/2025 at 02:32 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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2025
Section Cited
CCR
87303(f)

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87303 Maintenance and Operation
(f)All waste shall be located, stored, and disposed of in a manner that will not transmit communicable diseases or odors, pose a risk to health and safety, or provide a breeding place or food source for insects or rodents. This requirement
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Licensee immediately discarded trash bags. Deficiency cleared.
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not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed unsealed/ tied trash bags full of soiled incontinence briefs in laundry room with eggs, which poses an potential health, safety or personal rights risk to persons in care.
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Type B
04/25/2025
Section Cited
CCR87555(b)(23)

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87555 General Food Service Requirements(b) The following food service requirements shall apply:
(23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food
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Licensee immediately removed eggs and put them inside the house in refrigerator. Deficiency cleared.
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infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation large container of eggs left on a shelf unrefrigerated in laundry room, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
Page: 8 of 11
Document Has Been Signed on 04/24/2025 05:24 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/24/2025 at 02:34 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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2025
Section Cited
CCR
87309(a)

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87309 Storage Space and Access
(a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to
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Licensee to submit LIC9098 self-certifying laundry room door will remain locked and/or keep all cleaning supplies and toxins inaccessible to residents.
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residents are in locked storage and are not left unattended if outside the locked storage. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that door to laundry room from facility unlocked; LPAs observed unsecured cleaning products in metal cabinet found unlocked in laundry room, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
05/01/2025
Section Cited
CCR87463(a)

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87463 Reappraisals (a) The pre-admission appraisal...shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first...For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement not met
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Licensee to submit completed current reappraisals for R1, R2, R3, R4, and R5 by 5/2/25
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by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R1, R2, R3, R4, and R5 all did not have current appraisals on file,
which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
Page: 9 of 11
Document Has Been Signed on 04/24/2025 05:24 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/24/2025 at 02:34 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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/01/2025
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...
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Licensee to submit LIC9098 self-certifying they will submit incident reports to CCL for all residents when required by regulation by plan of correction due date.
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This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that licensee did not submit to CCL an Incident Report for R3 or R4 after they experienced incidents that required one be submitted, which poses a potential health, safety or personal rights risk to persons in care.

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Type B
05/01/2025
Section Cited
CCR87625(b)(3)

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87625 Managed Incontinence
(b)...the licensee shall be responsible for the following:(3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement not met by licensee as evidenced by: Based on
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Licensee to submit LIC9098 self-certifying they will keep residents and the facility free from incontinence odors by plan of correction due date.
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LPA and Admin observation, the licensee did not comply with the section cited above in that LPAs observed an extremely strong urine odor in room five (5) and odor in room two [2B], which poses a potential health, safety or personal rights risk to persons in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
Page: 10 of 11
Document Has Been Signed on 04/24/2025 05:24 PM - It Cannot Be Edited


Created By: Christi Coppo On 04/24/2025 at 04:28 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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2025
Section Cited
CCR
87465(h)(4)

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87465 Incidental Medical and Dental Care
(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
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Licensee to submit LIC908 self certifying that they will not alter prescription medication labels by plan of correction due date.
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alter a prescription label. This requirement not met by licensee as evidenced by: Based on LPA and Admin observation, the licensee did not comply with the section cited above in that R3's prescription medication had it's label partially removed, which poses a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2025


LIC809 (FAS) - (06/04)
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