496802052-5-6-2026-21-AS-RFRK-DTTVGZ-20260506162623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 05/06/2026
Date Signed: 05/06/2026 04:26:40 PM

Document Has Been Signed on 05/06/2026 04:26 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 RCFE		FACILITY NUMBER:	496802052
ADMINISTRATOR/ DIRECTOR:	ALICDAN JR, EDWARD		FACILITY TYPE:	740
ADDRESS:	3101 BRUSH CREEK ROAD		TELEPHONE:	(707) 537-0399
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95404
CAPACITY: 13		CENSUS: 8	DATE:	05/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:40 AM
MET WITH:	Edward Alicdan Jr, Administrator Luningning Alicdan, Licensee		TIME VISIT/ INSPECTION COMPLETED:	04:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a 1-Year Required Visit. Administrator Edward Alicdan, arrived at approximately 9:15 AM. Licensee Luningning Alicdan arrived at 11:25 AM. Betsy's II RCFE is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a large single story ranch house. The facility has a plan of operation for dementia care and programming on file. The facility has an approved fire clearance and total capacity for thirteen (13) residents of which eleven (11) residents may be non-ambulatory, and two (2) residents may be bedridden. Facility has an approved hospice waiver for three (3) residents. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were eight (8) Residents in care. LPA reviewed the Facility's Staff Roster and observed that staff member S1 was not associated to the facility in the Guardian Background Check system as required per regulations. The facility will be cited for this deficiency and a Civil Penalty of $500 will assessed for this violation. All other staff members were observed to be background cleared and associated to the facility per regulation. At approximately 9:10 AM, LPA toured the facility. All exits were clear and unobstructed. Facility fire extinguishers were last serviced and tagged in June, 2025. The automatic sprinkler system was serviced in 11/2025. The facility's fire alarm system was inspected and tagged in 5/2026. The facility was sufficiently lighted. LPA inspected eight (8) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 3/31/2026. Continued on 809-C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

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: 05/06/2026

NARRATIVE

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...Continued from 809

Hot water temperatures for all sinks in facility were found to be within Title 22 regulations of 105 to 120 degrees Fahrenheit. Facility smoke detectors and carbon monoxide detectors were tested and observed to be operational. During todays inspection of the physical plant LPA Frank made the following observations:

In the storage room in the common area, LPA observed that there was a can of paint and paint remover accessible to residents as the storage room was unlocked. In the sink to the immediate left of the storage room LPA observed unsecured cleaning products. Additionally, in the facility's office area a can of spray paint was observed to be unsecured. This deficiency will be cited. As this same deficiency was previously cited within the past year (10/24/2025 & 1/13/2026) a Civil Penalty of $250 will be issued.
In the same storage room noted above, LPA observed an unsecured prescription medication. This deficiency will be cited in the facility's Non-Compliance Inspection Report which is being completed today, 5/6/2026.
In the kitchen cabinets to the left of the stove top, LPA observed the area to have a build up of grease and to be extremely dirty. The facility will be cited for this deficiency.
Room number one (1) was observed to have a strong odor of urine. The resident of room one (1) is using incontinence products. The odor was observed to be strongest near the residents bed.

At approximately 11:45 AM, LPA reviewed five (5) resident files. Two (2) of five (5) resident files (for residents R1 & R2) were observed not to have signed Personal Rights documents. One (1) of five (5) resident files (for residents R2) was observed not to have a Pre-Placement Appraisal.

LPA reviewed five (5) staff files. One (1) of five (5) staff files (for staff member S2) was observed not to have proof of the required twenty (20) hours of annual training. One (1) of five (5) staff files (for staff member S2) was observed not to have a Medical Assessment or proof of a negative Tuberculosis (TB) test. The resident records and staff file deficiencies will be cited in the facility's Non-Compliance Inspection Report which is being completed today, 5/6/2026.

Continued on 809C2...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

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: 05/06/2026

NARRATIVE

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LPA unable to complete Annual Inspection. Annual Continuation Visit to be conducted at a later date.

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, Plan of Corrections, LIC 811 Confidential Names, LIC 9098 Self Certification, LIC 421FC, LIC 421BG 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: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/06/2026 04:26 PM - It Cannot Be Edited

Created By: Robert Frank On 05/06/2026 at 02:26 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: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that the kitchen cabinets were observed to be very dirty with some caked in dried grease or sauces which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2026
	Plan of Correction
1 2 3 4	Licensee or Administrator to provide photographs showing the kitchen cabinets have been cleaned throughly to Community Care Licensing by POC due date of 6/3/2026.

Type B

Section Cited

CCR

87309(a)

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 residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that paint and clearing products were observed in the storage room in the common area and in the sink cabinet next to the storage room which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/03/2026
	Plan of Correction
1 2 3 4	Licensee or Administrator to submit an LIC 9098 self certification that all toxic items will be kept inaccessable to residents to CCL by POC due date of 6/3/2026.

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: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/06/2026 04:26 PM - It Cannot Be Edited

Created By: Robert Frank On 05/06/2026 at 02:26 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: 05/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation & record review, the licensee did not comply with the section cited above in that Staff Member S1 was not associated to the facility in the Guardian Background Check System which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/20/2026
	Plan of Correction
1 2 3 4	Licensee or Administrator to associate staff member S1 to the facility in the Guardian Background Check System before they work again in the facility and to provide proof of association to the facility or submit an LIC 9098 stating that staff member S1 no longer works at the facility to Community Care Licensing (CCL) by POC due date of 5/20/2026.

Type B

Section Cited

CCR

87625(b)(3)

Managed Incontinence

(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, 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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that Room number one (1) was observed with a strong urine odor which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/17/2026
	Plan of Correction
1 2 3 4	Licensee or Administrator to submit an LIC 9098 self certifying that Room one (1) has been cleaned and no longer smells of urine to CCL by POC 6/17/2026.

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: 05/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2026

LIC809 (FAS) - (06/04)

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