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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:23:56 PM

Document Has Been Signed on 11/13/2024 03:23 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: 8DATE:
11/13/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:05 PM
MET WITH:Luningning AlicdanTIME VISIT/
INSPECTION COMPLETED:
03:38 PM
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LPA arrived unannounced to conduct a plan of correction visit and met with caregiver. LPA reached Licensee Luningning Alicdan via phone and discussed items including but not limited to: plans of corrections that have not been fulfilled, plans of corrections due for citations issued today, and civil penalties assessed today.

On 10/30/24 citations were issued for the following deficiencies with respective plans of correction:

87405(a) - Licensee to submit LIC500 showing what hours she is allocating for caregiving and what hours she is allocating to Admin duties. Hours reflected must be sufficient as indicated in the regulation. On 10/31/24 Admin submitted to CCL LIC500 showing Admin working 2 hours per day, Monday through Friday. Today 11/13/24, LPA discussed licensee being present at facility a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified and free from other responsibilities such that they can attend to the administration duties required as necessitated by the care needs of residents and requirements of staff (i.e. arranging doctor visits, updating care plans, and conducting staff training) Licensee agrees to submit updated LIC500 showing more than 10 hours per week dedicated to Administrating duties. Licensee will submit updated LIC500 by 11/18/24.

HSC1569.625(b)(2) - Facility to submit proof of online training for all staff Training to include the following information: Date, Training Topic, Name/Job Role, and Signatures by POC due date of 10/31/2024. On 10/31/24 licensee submitted training log with title of “on-line training” but did not specify the training topics covered. Licensee hand wrote “I have to enroll them again at CCO to the next training. I will call CCO and enroll them on Monday.” Today 11/13/24, LPA discussed with licensee the annual training of staff for this facility. LPA and licensee discussed that three [3] employees have 18,14, and 13 hours of the 20 required per regulation. LPA asked licensee if any more training hours had been completed since the last citation issued on 10/30/24. Licensee advised no additional training has been completed because licensee unable to log in on CCO website. Licensee explained that she has trouble navigating online services and keeping track of passwords. So, LPA could not verify with licensee that all staff have completed at least 20 hours of annual training (deficiency cited, see 809D. **civil penalty assessed**)

Continued on 809C...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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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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: 11/13/2024
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Continued from 809...

87303(e)(2) - Licensee to submit a water temperature log for the next 10 days. Temperature to be checked twice a day for all sinks starting on 06/20/2024. Log to include location of sink and time documented. Log to be submitted to CCL for review and approval by POC due date 10/31/2024. On 10/31/24 licensee submitted water temperature log but did not include location of sink and time documented. Today 11/13/24, LPA tested water temperature in the sink in the kitchen, in the main bath on side B, and rooms #1,#4, and #7. Licensee requested LPA use facility thermometer to get temperature readings in addition to LPA's state issued thermometer. LPA took water temperature readings using both LPA's thermometer and facility's thermometer. Water temperature readings were captured on video. Water temperatures measured at 111.5 degrees in kitchen, 128 degrees F in the main bath on side B, 109.4 degrees F in room #1, 109.1 degrees F in room #4, and 130 degrees F in room #7. The water temperature readings in the main bath on side B and in room #7 are not within the allowable range of 105 to 120 degrees F (deficiency cited, see 809D. **civil penalty assessed**)

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 deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

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

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2024 03:23 PM - It Cannot Be Edited


Created By: Christi Coppo On 11/13/2024 at 01:22 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: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2024
Section Cited
HSC
1569.625(b)(2)

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1569.625(b)(2)...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...four hours of which shall be specific to postural supports, restricted health conditions, and hospice care..
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Facility to submit proof of staff enrollment for all staff on CCO website to CCL by plan of correction due date. Licensee to submit completed annual staff training totalling 20 hours no later than 11/27/24. civil penalty assessed
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This requirement was not met by licensee as evidenced by: failure to satifsy plan of correction for this regulation deficeincy issued on 10/30/2024, which poses an immediate health, safety, and/or personal rights risk to resident in care.
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Type A
11/14/2024
Section Cited
CCR87303(e)(2)

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87303 Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be... (2) Faucets used by residents ...shall deliver hot water. Hot water temperature controls shall be maintained ... to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C)...
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Facility to submit plan to regulate water tempertaure such that it remains within the regualtion requirements and submit phopgraphic proof of complaince with regualtion. Licensee agrees to submit photographs of water temperature readings with therometer itself and its
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This requirement was not met by licensee as evidenced by: water temperature over 120 degrees F in two [2] out of five [5] sinks measured, which poses an immediate health, safety, and/or personal rights risk to resident in care.
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reading present in picture. Picture to include number of room and/or location of where water temperature is being measured. Licensee agrees to take at least two readings per day, in rooms identified in 11/13/24 report, beginning on 11/14/24. Licensee will come to CCL Santa Rosa regional office to show all water temperature reading pictures on 11/26/24. civil penalty assessed.
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
LICENSING EVALUATOR NAME:Christi Coppo
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
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