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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802052
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:31:38 AM

Unsubstantiated


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
08/01/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240801170623
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: DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
10:14 AM
MET WITH:Luningning AlicdanTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility not administering medication per physician orders, neglect resulting in resident death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At approximately 9:00AM, Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to deliver findings regarding the above allegation.

Facility not administering medication per physician orders, Neglect resulting in resident death – Complaint alleges that resident, R1 was given an incorrect medication causing R1 to require emergency intervention and eventually passing away at the hospital. Statement from Licensee indicated that they misspoke when reporting to emergency personnel and the resident was not given an incorrect medication. Review of medical records do not show that an overdose was a reason for or contributed to R1’s death.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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