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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 05/06/2026
Date Signed: 05/06/2026 04:34:05 PM

Document Has Been Signed on 05/06/2026 04:34 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: 8DATE:
05/06/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Edward Alicdan Jr, Administrator
Luningning Alicdan, Licensee		TIME VISIT/
INSPECTION COMPLETED:
04:45 PM
NARRATIVE
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At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a Non-compliance inspection. Administrator Edward Alicdan, arrived at approximately 9:15 AM. Licensee Luningning Alicdan arrived at 11:25 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
· 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. 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
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NCC...Continued from 809

LPA reviewed records pertaining to compliance with areas including staff training records, maintaining staff and resident records.

During today's physical plant inspection, LPA made the following observations:
  • In the storage room in the common area LPA observed an unsecured prescription medication. This deficiency will be cited. As this same deficiency was previously cited within the past year (1/13/2026) a Civil Penalty of $1000 will be issued.
  • 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 to have a Medical Assessment or proof of a negative Tuberculosis (TB) test.
These deficiencies 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, Plan of Corrections, LIC 811 Confidential Names, LIC 9098 Self Certification, LIC 421IM 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 04:34 PM - It Cannot Be Edited


Created By: Robert Frank On 05/06/2026 at 02:59 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2026
Section Cited
HSC
1569.625(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, eight hours of which shall be dementia care training...

This requirement is not met as evidenced by:
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Licensee to submit proof that staff member S2 has completed their annual training to Community Care Licensing (CCL) by POC due date of 6/3/2026.
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Based on observation & record review, the licensee did not comply with the section cited above in that one (1) of (5) staff members (S2) did not complete their 2025 annual training which poses a potential health, safety or personal rights risk to persons in care.
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Type B
06/03/2026
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...shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months...
This requirement is not met as evidenced by:
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Licensee to submit proof that staff member S2 has received a medical assessment and proof of a negative TB test to CCL by POC due date of 6/3/2026.
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Based on observation & record review, the licensee did not comply with the section cited above in that staff member S2 did not have a medical assessment or proof of a negative TB test in their personal record 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: 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 04:34 PM - It Cannot Be Edited


Created By: Robert Frank On 05/06/2026 at 03:14 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/27/2026
Section Cited
CCR
87468(b)(1)(A)

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87468 Personal Rights (b) At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy of: (1) The personal rights of residents specified in Sections 87468.1...
This requirement is not met as evidenced by:
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Licensee to submit signed personal rights document for residents R1 & R2 to Community Care Licensing (CCL) by POC due date of 5/27/2026.
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Based on observation & record review, the licensee did not comply with the section cited above in that residents R1 & R2 did not have signed personal rights documents in their records which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/27/2026
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 completed and signed pre-placement appraisal for resident R2 to CCL by POC due date of 5/27/2026.
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Based on observation & record review, the licensee did not comply with the section cited above in that resident R2 did not have a completed and signed pre-placement appraisal in their records 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: 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 04:34 PM - It Cannot Be Edited


Created By: Robert Frank On 05/06/2026 at 03:32 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: 05/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/07/2026
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...

This requirement is not met as evidenced by:
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Licensee to submit proof that all staff members have undergone medication management training after 5/6/2026 to Community Care Licensing by POC due date of 5/7/2026.
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Based on observation, the licensee did not comply with the section cited above in that a prescribed medication was left unsecured in the storage room in the common area of the facility 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: 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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