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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 01/13/2026
Date Signed: 01/13/2026 01:55:16 PM

Document Has Been Signed on 01/13/2026 01:55 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 JR, EDWARDFACILITY TYPE:
740
ADDRESS:3101 BRUSH CREEK ROADTELEPHONE:
(707) 537-0399
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY: 13CENSUS: 10DATE:
01/13/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:55 AM
MET WITH:Luningning Alicdan, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:10 PM
NARRATIVE
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At approximately 8:55 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. Licensee Luningning Alicdan arrived at 9:10 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: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2026
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: 01/13/2026
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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.

During today's physical plant 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.
-LPA observed that a storage room in a common area was unlocked and that there were unsecured toxins and insulin hypodermic needles in the room. This deficiency will be cited. As this same deficiency was previously cited within the past year (4/24/2025 & 10/24/2025) a Civil Penalty of $250 will be issued.
-An over the counter (OTC) medication was observed to be unsecured in a resident's room. During file review LPA observed that the resident (R3) was not allowed to administer their own prescription or PRN (pro re nata) medications. This deficiency will be cited. As this same deficiency was previously cited within the past year a Civil Penalty of $250 will be issued.

During today's inspection, LPA reviewed three (3) residents files and two (2) staff files. During file review, LPA observed the following:
-One (1) of three (3) residents' files (for resident R1) was observed not to contain any emergency contact information. This deficiency will be cited.
-One (1) of three (3) residents' files (for resident R2) was observed not to contain an LIC 603 Preplacement Appraisal. This deficiency will be cited.
Continued on 809-C2...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
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: 01/13/2026
NARRATIVE
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...Continued from 809-C

-One (1) of three (3) residents' files (for resident R3) was observed not to have a licensed medical professional's order or prescription for a PRN (pro re nata) medication. Resident R3 is not allowed to administer their own prescription or PRN medications. This Deficiency will be cited.
-One (1) of two (2) staff files was observed not to contain a Medical Assessment or proof of a negative tuberculosis test. This Deficiency will be cited.


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 Caregiver Nicadao Wilhelfortes . 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: 01/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/13/2026 01:55 PM - It Cannot Be Edited


Created By: Robert Frank On 01/13/2026 at 12:20 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: 01/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/27/2026
Section Cited
CCR
87506(b)(8)

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87506 Resident Records (b)Each resident’s record shall contain at least the following information: (8)Names, address, and telephone numbers of the resident’s representative, as defined in Section 87101(r), to be notified in case of accident, death, or other emergency. This requirement is not met as evidenced by:
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Licensee to submit a signed LIC 601 Identification and Emergency Information form for resident R1 to Community Care Licensing (CCL) by POC due date of 1/27/2026.
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Based on observation & record review, the licensee did not comply with the section cited above in that 1 of 3 residents records (for R1) did not contain Emergency Contact Information which poses a potential health, safety or personal rights risk to persons in care.
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Type B
01/27/2026
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs...
This requirement is not met as evidenced by:
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Licensee to submit a signed LIC 603 Preplacement Appraisal Information for Resident R2 to Community Care Licensing by POC due date of 1/27/2026.
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Based on observation & record review, the licensee did not comply with the section cited above in that 1 of 3 residents files (for resident R2) did not contain an LIC 603 Preplacement Appraisal Information form 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: 01/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/13/2026 01:55 PM - It Cannot Be Edited


Created By: Robert Frank On 01/13/2026 at 12:41 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: 01/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2026
Section Cited
CCR
87465(h)(2)

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87465Incidental 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 an LIC 9098 Self Certification stating that ALL medications will not be left unsecured by POC due date of 1/14/2026. Additionally, Licensee will re-train ALL staff members in Medication Management. Proof of training to be submitted to Community Care Licensing by
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Based on observation, the licensee did not comply with the section cited above in that over the counter PRN medication was observed to be unsecured in Room #2 which poses an immediate health, safety or personal rights risk to persons in care.
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no later than 1/28/2026.

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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: 01/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/13/2026 01:55 PM - It Cannot Be Edited


Created By: Robert Frank On 01/13/2026 at 01:04 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: 01/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/14/2026
Section Cited
CCR
87465(c)(1)

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87465 Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing..(1)There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication... This requirement is not met as evidenced by:
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Licensee will submit an LIC 9098 Self Certification stating that ALL medications will not be left unsecured by POC due date of 1/14/2026. Additionally, Licensee will re-train ALL staff members in Medication Management. Proof of training to be submitted to Community Care Licensing by
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Based on observation & record review, the licensee did not comply with the section cited above in that PRN medication was provided to Resident R3 without a licensed medical professional's order or prescription, which poses an immediate health, safety or personal rights risk to persons in care.
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no later than 1/28/2026.
Type A
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Section Cited
CCR87309(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 and insulin syringes will kept secured at the facility in the future to Community Care Licensing (CCL) by POC due date of 1/14/2026.
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Based on observation, the licensee did not comply with the section cited above in that unsecured toxins and insulin syringes were observed in a storage room 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: 01/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2026


LIC809 (FAS) - (06/04)
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