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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 10/24/2025
Date Signed: 10/24/2025 04:01:49 PM

Document Has Been Signed on 10/24/2025 04:01 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: 11DATE:
10/24/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Luningning Alicdan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. Licensee Luningning Alicdan arrived at 9:05 AM.

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

Continued on 809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2025
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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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: 10/24/2025
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...Continued from 809

· 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.

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

LPA reviewed the Facility's Staff Roster and found that all staff on-site were background cleared and associated to the facility per regulation.

LPA reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records, and pre-pouring of medication.

LPA conducted interviews and made observations pertaining to Administrators ensuring of personal rights of residents in care and ensuring resident needs are met.

The facility is being cited for not having a currently certified Administrator. As this is the third (3) time the facility is being cited (8/6/2025 & 8/22/2025) for this deficiency within one (1) year a Civil Penalty of $250.00 is being assessed.



During today's inspection, LPA made the following observations:
-Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit.
-A bottle of Povidone/Iodine was observed to be unsecured in a resident's bathroom. In addition, LPA observed that the door to the laundry room was unlocked. Within the laundry room, there were unsecured toxins. LPA further observed that the storage room in a common area was unlocked and that there were unsecured toxins in the room. These deficiencies will be cited. As this same deficiency was previously cited within the past year (4/24/2025) a Civil Penalty of $250 will be issued.
-In a kitchen cabinet two (2) condiment items that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. This deficiency will be cited. As this same deficiency was previously cited twice (2) times within the past year (4/24/2025 & 6/11/2025) a Civil Penalty of $250 will be issued.
Continued on 809-C2...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
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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: 10/24/2025
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...Continued from 809-C

-In the common area, next to the storage room, a parabolic dish heater was observed to not have a protective screen to prevent the risk of burns or fire. This deficiency will be cited. The licensee unplugged and removed the heater during today's inspection so the deficiency will be cleared.
-In the cabinet immediately outside of the kitchen area, across from a bathroom, food products and cleaning products were observed to be stored together. This deficiency will be cited.
-In the common area, next to the storage room a cabinet with prescription items was observed to be unlocked and accessible to residents. As this same deficiency was previously cited twice (2) times within the past year (6/11/2025 & 8/22/2025) a Civil Penalty of $250 will be issued.

During today's inspection, LPA reviewed four (4) residents files and two (2) staff files. LPA observed an incomplete LIC 624 Unusual Incident report in resident R4's personal records. This LIC 624 was not sent to Community Care Licensing (CCL) within the required seven (7) days from the date of the incident. Additionally, LPA observed that a required LIC 9186 Client Death Report had not be filled for resident R5. These deficiencies will be cited. As this same deficiency was previously cited within the past year (4/24/2025) a Civil Penalty of $250 will be issued. LPA observed that two (2) of two (2) staff files had all required documentation including First Aid and CPR certification and proper training documentation.

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

Exit interview conducted. Copy of report, LIC-809Ds, 811 Confidential Names, LIC 421FCs, Plan of Corrections and Appeal Rights discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2025 04:01 PM - It Cannot Be Edited


Created By: Robert Frank On 10/24/2025 at 01:46 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: 10/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2025
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...and other similar items which could pose a danger to residents are in locked storage...This requirement is not met as evidenced by:
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Licensee will submit an LIC 9098 Proof of Correction self certifying that all toxins will kept secured at the facility in the future to Community Care Licensing (CCL) by POC due date of 10/27/2025.
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Based on observation, the licensee did not comply with the section cited above in that unsecured toxins were observed in a residents bathroom, the laundry room and the storage room which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
10/27/2025
Section Cited
CCR87465(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 is not met as evidenced by:
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Licensee will submit LIC9098 to CCL self certifying that all medications will be kept in a safe and locked place. Licensee will further self certify that it has been discussed with all employees that both prescription and PRN medications be secured at all times. This to be done by POC Due Date of 10/27/2025.
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Based on LPA observation, the licensee did not comply with the section cited above in that a medication cabinet in common area, next to the storage room was unlocked, which poses a 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:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2025


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Document Has Been Signed on 10/24/2025 04:01 PM - It Cannot Be Edited


Created By: Robert Frank On 10/24/2025 at 02:10 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: 10/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/27/2025
Section Cited
CCR
87307(e)(1)(A)

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87307 Personal Accommodations and Services (e)The licensee shall supervise residents as needed...when residents are in proximity to or when there is use of the following items:(1)... heaters,...and other heating devices.(A)Heating devices shall have protective mechanisms...in order to reduce the risk of burns or fire.
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Licensee removed heater during today's inspection. Deficiency cleared.
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This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in that in the common area, next to the storage room, a parabolic dish heater was observed to not have a protective screen which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
10/27/2025
Section Cited
CCR87405(a)

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87405 Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person...

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Licensee will provide the documents required to make a currently certified administrator the active Administrator of the facility to Community Care Licensing by the POC due date of 10/27/2025.
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Based on record review, the licensee did not comply with the section cited above in that the facility does not have a currently certified Administrator 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:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2025


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Document Has Been Signed on 10/24/2025 04:01 PM - It Cannot Be Edited


Created By: Robert Frank On 10/24/2025 at 02:30 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: 10/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2025
Section Cited
CCR
87555(b)(23)

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87555:General Food Service Requirements(b)The following ...requirements shall apply: (23) All readily perishable foods... capable of supporting...progressive growth of micro-organisms which can cause food infections..shall be stored...at appropriate temperatures.
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Licensee will submit an LIC 9098 self certifying that they have trained all staff in food service safety to Community Care Licensing by POC due date of 11/14/2025.
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This requirement is not met as evidenced by:Based on observation, the licensee did not comply with the section cited above in that that two (2) condiments that were required to be refrigerated after opening, were left unrefrigerated in a kitchen cabinet. which poses a potential health, safety or personal rights risk to persons in care.
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Type B
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Section Cited
CCR87555(b)(25)

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87555 General Food Service Requirements (b)The following food service requirements shall apply: (25)Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies. This requirement is not met as evidenced by:
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Licensee to store all cleaning products away from food products. Licensee will submit an LIC 9098 self certifying that they have trained all staff in food service safety to Community Care Licensing by POC due date of 11/14/2025.
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Based on observation, the licensee did not comply with the section cited above in In the cabinet immediately outside of the kitchen area, across from a bathroom, food products and cleaning products were observed to be stored together. 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:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/24/2025 04:01 PM - It Cannot Be Edited


Created By: Robert Frank On 10/24/2025 at 02:50 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: 10/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2025
Section Cited
CCR
87211(a)(1)

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87211Reporting Requirements (a)Each licensee shall furnish to the licensing agency such reports...(1) A written report shall be submitted to the licensing agency...for the resident within seven days...This report shall include the resident's name, age....(A) Death of any resident...
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Licensee to submit both the an LIC 624 Unusual Incident report for R4 and an LIC 9186 Client Death Report for R5. Licensee will also submit an LIC 9098 Proof of correction form self certifying that in the future they will submit all forms per CCR 87211 in the required time frame
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This requirement is not met as evidenced by:Based on observation and record review, the licensee did not comply with the section cited above in that an LIC 624 Unusual Incident report for R4 and an LIC 9186 Client Death Report for R5 was not sent to CCL which poses a potential health, safety or personal rights risk to persons in care.
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to Community Care Licensing by POC due date of 11/7/2025.

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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:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2025


LIC809 (FAS) - (06/04)
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