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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496802052
Report Date: 10/24/2024
Date Signed: 10/24/2024 04:48:09 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
10/18/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20241018130423
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:
10/24/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Luningning Alicdan, LicenseeTIME COMPLETED:
05:03 PM
ALLEGATION(S):
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Licensee does not ensure sufficient staffing to meet residents’ care needs.
Staff did not respond to resident's request for assistance in a timely manner.
Resident was left unattended after a fall for an extended period of time.
Facility has bed bugs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christi Coppo arrived at this facility unannounced, to open an investigation into the above allegations.

Complaint alleges: licensee does not ensure sufficient staffing to meet residents’ care needs, staff did not respond to resident's request for assistance in a timely manner, and resident was left unattended after a fall for an extended period of time.

LPA met licensee in the driveway upon arrival and told her of the allegations. Licensee immediately identified the resident that fell as being R1. Licensee was working the NOC shift that night. She heard R1 yell around 9:45pm. Licenseee said she went right to R1's room. Licensee walked in R1's room and R1 was on the floor, by their bed. Licensee did assessment to see if R1 was bleeding.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
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 3
Control Number 21-AS-20241018130423
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: 10/24/2024
NARRATIVE
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continued from 9099...

Licensee explained she tried to get R1 up by herself, but she couldn’t because R1 is too heavy and so she gave him a pillow and blanket. Licensee explained to LPA that R1 did not have a skin tear or anything as a result of falling and the room was clean; no feces or urine present on the walls or in R1's room. Licensee said she then left R1's room to call caregiver (S3) to come and help her get R1 off of the floor. S3 was not present at the facility, S3 was in Windsor at the time of licensee's call. Licensee advised LPA that S3 arrived approximately 30 minutes later. After arriving, S3 helped R1 up from the floor and put R1 back in bed. So, based on interview with licensee, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Complaint alleges facility has bed bugs. Per LPA interview with licensee, licensee is aware of on-going bed bug issue at facility. LPA and licensee spoke to most recent pest exterminator (E3) via telephone. Per LPA and licensee interview with E3, the facility was recently treated on 10/4/24 for bed bugs found in rooms 7, 8, 9, and 10. Per E3, the treatments given were a pest spray and a steam treatment. LPA clarified if steam treatment was the same as heat treatment and exterminator said no, that the two are different treatments. E3 said heat treatment would probably be the next step, where the company would tarp the house and do an all encompassing heat treatment on the entire facility. E3 said however that heat treatment is not covered under the licensee's current warranty and that it would be an additional cost. E3 further explained that they are unsure of the next steps to take that would be best to solve the issue since it seems so pervasive. So, E3 gave LPA and licensee their managers' phone number to call and inquire. LPA and licensee called both managers' phone numbers but were unsuccessful in reaching either one. Subsequently, LPA toured the facility and obtained photographic evidence of bed bugs still present in facility. LPA found bed bugs in room 10B and outside of rooms 8,9, an 10 in the hallway under a table stand in a sticky box. Based on LPA observation and photographic evidence, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies cited on the attached LIC 9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with licensee and a copy of this report was given. **Civil penalty assessed for repeat deficiency within 12 months.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20241018130423
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: 10/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/06/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents... (a) ... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) to care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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Facility to submit plan to provide adequate staffing such that staff are sufficient in numbers, qualifications, and competency to meet all residents' needs by plan of correction due date during business hours. If plan is found to be adequate by CCL, then
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This requirement was not met by licensee as evidenced by: Based on LPA interview with licensee and photographic evidence obtained,This requirement was not met by license as evidenced by: LPA interview with licensee indicating R1 fell on to the floor but licesee could not pick R1 up unasssited. R1 waited at least 30 minutes before receiving assistance, which poses a immediate health, safety, and personal rights risk to resident in care.
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facility to then submit LIC500 reflecting that facility has staff sufficient in numbers, qualifications, and competency to meet all residents' needs no later than 11/01/2024. If the plan is not found to be acceptable, licensee will come in to Regional Office for compliance meeting with CCL management.
Type B
11/06/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include... procedures for the safety and well-being of residents, employees and visitors.
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Licensee to ensure facility is free from bed bugs by plan of correction due date. Given that previous spray and steam treatments did not work, licensee agrees to tarp and treat facility with heat and/or perform the service recommened by exterminator E1 or E2 that will be most
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This requirement was not met by license as evidenced by: Facility on-going issue of bed bugs present at facility is known by licensee and LPA obtained photographic evidence, which poses an potential health, safety, and personal rights risk to resident in care.
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effective to ensure facility is free from bed bugs. *civil penalty assessed for repeat violation within 12 months*
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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3