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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802052
Report Date: 07/10/2026
Date Signed: 08/05/2026 02:01:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/14/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260414093622
FACILITY NAME:BETSY'S II RCFEFACILITY NUMBER:
496802052
ADMINISTRATOR:ALICDAN JR, EDWARDFACILITY TYPE:
740
ADDRESS:3101 BRUSH CREEK ROADTELEPHONE:
(707) 537-0399
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:13CENSUS: 8DATE:
07/10/2026
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Luningning Alicdan, LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff administered medication without a doctor's prescription

Staff do not ensure that resident's medication is administered as prescribed

Staff falsified resident medication administration records
INVESTIGATION FINDINGS:
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Amended: Civil Penalty of $500 has been removed:

Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver findings regarding the above allegations and met with Licensee Luningning Alicdan.
During the course of the investigation LPA conducted a facility visit, conducted interviews, collected and reviewed documents.
Complaint alleges that staff administered medication without a doctor’s prescription. Witness W1 stated that while visiting resident R1 on 4/12/2026, they observed R1 to be slumped over in their chair. W1 contacted witness W2 who said to check to see if the facility had been administering Medication-1 to the resident. W2 had previously dropped off the bottle of Medication-1 for R1 at the facility. W1 then spoke with facility staff member S1 who provided the bottle of medication-1 to W1. W1 observed the amount of medication to be depleted.
Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20260414093622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/10/2026
NARRATIVE
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...Continued from 9099

Staff member S2 then arrived at the facility. W1 asked S2 to view the medication logs for medication-1. S2 provided the Pro Re Nata (PRN-given as needed) logs to W1 who photographed them. These photographs were provided to Community Care Licensing (CCL). The PRN log shows that medication-1 had been given to R1 sixteen (16) times between the dates of 3/26/2026 to 4/11/2026. R1’s medication list provided by Kaiser Permanente dated 3/23/2026 does not show medication-1 as a prescribed medication. The facility did not receive a doctor’s order for medication-1 until 4/3/2026. The PRN logs show the facility administered medication-1 that was not prescribed for R1 until 4/3/2026 on the dates of 3/26/2026; 3/27/2026; 3/28/2026; 3/29/2026; 3/30/2026; 4/1/2026 and 4/2/2026. California Code of Regulations (CCR) 87465 (e) states, “For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication.” Based on LPA’s observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Complaint alleges that staff do not ensure that resident’s medication is administered as prescribed. The bottle of medication-1 listed the following instructions on its label, “Take 1/2 to 1 tablet by mouth daily for ‘redacted’ up to 3 times a week. Use sparingly.” Within the week of 3/26/2026 to 4/1/2026 LPA observed that medication-1 was administered to the resident on the dates of 3/26/2026; 3/27/2026; 3/28/2026; 3/29/2026; 3/30/2026 and 4/1/2026. As medication-1 was administered to R1 six (6) times in a week, the amount of medication administered exceeds the doctor’s orders as shown on the prescription label. In addition, the facility’s Centrally Stored Medication and Destruction Records for medication-1 were incomplete. The record was observed not to have the instructions, expiration date, date filled, prescribing physician, prescription number and number of refills listed. Furthermore, medication-1’s prescription label was observed to show that the medication should be discarded after 5/5/2022. Based on LPA’s observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 Chapter 8, are being cited on the attached 9099D.

Continued on 9099-C2...

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260414093622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/10/2026
NARRATIVE
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...Continued from 9099-C

Complaint alleges that staff falsified resident medication administration records. On 4/12/2026 while at the facility, W1 asked S2 to view the medication logs for medication-1. S2 provided the Pro Re Nata (PRN-given as needed) logs to W1 who photographed them. These photographs were provided to Community Care Licensing (CCL) by W1 on 4/22/2026. The PRN log photographed shows that medication-1 had been given to R1 sixteen (16) times between the dates of 3/26/2026 to 4/11/2026. During a facility inspection on 4/23/2026 LPA asked staff member S2 to provide the same PRN medication logs for medication-1. The logs provided to LPA by S2 on 4/23/2026 show that medication-1 was only administered to R1 two (2) times on 4/10/2026 and 4/11/2026. In an interview with staff member S2 on 4/23/2026 LPA asked staff member S2 multiple times to confirm that medication-1 had only been given to resident R1 twice. S2 confirmed to the LPA that medication-1 had only been administered to R1 twice. The PRN logs for medication-1 provided to the LPA do not match the previously photographed PRN logs with fourteen (14) instances of medication-1 administration having been omitted. Based on LPA’s observations, interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Title 22, Division 6, Health Safety Code, Chapter 3, are being cited on the attached 9099D.

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-9099, LIC-9099-Cs, LIC-9099Ds, LIC-421IM, Plan of Corrections and Appeal Rights discussed and provided to Licensee Alicdan. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20260414093622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2026
Section Cited
CCR
87465(e)
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87465 Incidental Medical and Dental Care (e) For every prescription and non prescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, ...
This requirement is not met as evidenced by:
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Licensee and all facility staff who assist with the self-administration of medicine shall complete eight (8) hours of in-service training on Medication Management and medication related issues.
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Based on interviews & record review, the licensee did not comply with the section cited above in that the facility administered medication-1 that was not prescribed for R1 until 4/3/2026 was administered seven (7) times between the dates of 3/26/2026-4/2/2026. which poses an immediate health, safety or personal rights risk to persons in care.
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Licensee to provide proof of training and all training curriculum to Community Care Licensing by POC due date of 7/13/2026.
Type A
07/13/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
This requirement is not met as evidenced by:
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Licensee is to have a 3rd party pharmacy or pharmacy consultant complete a full audit of the facility’s medications and medication management program. Licensee to provide Community Care
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Based on observation & record review, the licensee did not comply with the section cited above in that medication-1 was administered to R1 six (6) times in a week, the amount of medication administered exceeds the doctor’s orders as shown on the prescription label which poses an immediate health, safety or personal rights risk to persons in care.
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Licensing the name of the 3rd party pharmacy or pharmacy consultant, audit findings and the date on which the audit will be conducted to Community Care Licensing by POC due date of 7/13/2026.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260414093622
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/13/2026
Section Cited
CCR
87465(h)(6)(E)
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87465 Incidental Medical and Dental Care (h)The following... to medications which are centrally stored: (6) The licensee shall be responsible...is maintained for at least one year and includes: (E) The prescription number...This requirement is not met as evidenced by:
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Licensee to submit completed Centrally Stored Medication and Destruction Records for all facility residents to Community Care Licensing by POC due date of 7/13/2026.
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Based on observation & record review, the licensee did not comply with the section cited above in that the facility’s Centrally Stored Medication and Destruction Records were observed not to have the prescription number which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
07/13/2026
Section Cited
HSC
1550(c)
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1550 Licenses or administrator...The department may...suspend or revoke, any license,...(c) Conduct which is inimical to the health, morals, welfare, or safety of either the people of this state or an individual in, or receiving services from, the facility or certified family home. This requirement is not met as evidenced by:
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Licensee to take their required twenty (20) hours of annual training from a vendor approved by Community Care Licensing. Proof of all twenty (20) hours to be submitted to Community Care Licensing by POC due date of 7/13/2026.
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Based on interview and record review, the licensee did not comply with the section cited above in that the PRN logs for medication-1 provided to the LPA do not match the previously photographed PRN logs with fourteen (14) instances of medication-1 administration having been omitted 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.
SUPERVISOR'S NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 07/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5