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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802052
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:41:23 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
08/03/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230803103840
FACILITY NAME:BETSY'S II RCFEFACILITY NUMBER:
496802052
ADMINISTRATOR:ALICDAN, LUNINGNINGFACILITY TYPE:
740
ADDRESS:3101 BRUSH CREEK ROADTELEPHONE:
(707) 537-0399
CITY:SANTA ROSASTATE: CAZIP CODE:
95404
CAPACITY:13CENSUS: 11DATE:
10/10/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Caregiver, Williforte NicdaoTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff are not properly trained to care and supervise residents
Staff does not ensure facility is free of pests and rodents
Staff is mismanaging resident's medication logs
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Victoria Bertozzi and Helena Rummonds arrived unannounced to deliver findings regarding the above allegations and met with caregiver, Williforte Nicdao. Backup Administrator, Edward Alicdan was available by phone. Licensee/Administrator, Luningning "Bot" Alicdan was unavailable.

During investigation LPAs conducted interviews, made observations and reviewed files.

Staff are not properly trained to care and supervise residents – Complaint alleges that a new staff who was not trained was left “in charge” while Licensee was out of town. LPA confirmed through document review that not all staff are trained per regulation. Per interview with Licensee, untrained staff worked alone with residents in care.

Continued on LIC9099A
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
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-20230803103840
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: 10/10/2023
NARRATIVE
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Continued from LIC9099

Staff does not ensure facility is free of pests and rodents – Complaint alleges that facility has a rat, cockroach, spider and bed bug infestation resulting in residents and staff getting bed bug bites on them. LPA was able to confirm through interviews and observation that facility has insects inside of the facility but was not able to identify the type of insects. Facility has routine service by a vendor but it is unclear if they conduct treatment inside the facility.

Staff is mismanaging resident's medication logs – Complaint alleges that medication is prepared a week in advance and that medications are not logged correctly. Per interview and LPA observation, medications are being prepared in advance, however, it does not appear that medications are being poured a week in advance. Review of the Centrally Stored Medication Log revealed that staff had input incorrect information including medication fill date, dosage amount and prescribing doctor.

Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230803103840
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: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2023
Section Cited
CCR
87411(c)
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87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69. This requirement was not met based on record reviews showing that
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Licensee will submit a planned training schedule to LPA that will ensure that staff are trained per regulation no later than POC due date, 10/11/2023.
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staff was not trained per regulation. This is an immediate risk to the Health and Safety of residents in care.
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Type A
10/11/2023
Section Cited
CCR
87307(d)(2)
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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement was not med based on interview and observation
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Licensee to send a written plan how they will ensure that there are no insects or rodents in the facility no later that 10/11/2023.
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showing that facility has insects inside the facility. This is an immediate risk to the health and safety of residents 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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20230803103840
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: 10/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/16/2023
Section Cited
CCR
87465(h)(5)
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87465 Incidental Medical and Dental Care
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
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Licensee to submit self certification that they will no longer be pre-pouring medications by POC due date of 10/16/2023.
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This requirement is not met as evidenced by:
based on observation and interview facility is pre-pouring medication.
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Type B
10/24/2023
Section Cited
CCR
87465(6)
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87465 Incidental Medical and Dental Care (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident... includes:
(A)The name of the resident for whom prescribed.
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Licensee to audit medications and update centrally stored log so that it is accurate and submit self certification to LPA showing it is completed by POC due date of 10/24/2023.
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(B) The name of the prescribing physician., (C) The drug name, strength and quantity., (D) The date filled., (E) The prescription number and the name of the issuing pharmacy., (F) Instructions, if any, regarding control and custody of the medication.
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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.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5