<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803767
Report Date: 07/11/2023
Date Signed: 07/11/2023 03:40:03 PM


Document Has Been Signed on 07/11/2023 03:40 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:BETSY'S BOARD AND CAREFACILITY NUMBER:
496803767
ADMINISTRATOR:ALICDAN, LUNINGNINGFACILITY TYPE:
740
ADDRESS:184 CALISTOGA RDTELEPHONE:
(707) 623-9874
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY:6CENSUS: 5DATE:
07/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Licensee, Luningning Alicdan
Caregiver, Marilou Vega Imperial 		TIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Betsy's Board and Care for the purpose of conducting a Required 1 year inspection. Upon arrival, LPA was greeted at the front door by Caregiver, Marilou Vega Imperial. However, the Caregiver was not background cleared nor associated to the facility (See LIC 809D and LIC421BG). Licensee arrived 30 minutes later. Licensee disclosed to the LPA that the caregiver has been working for 5+ days at the facility. LPA educated the Licensee regarding the importance of having caregivers background cleared and associated to the facility.

LPA and the Licensee toured the 1 story facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on June 2023 at the time of the inspection. First Aid kit was fully stocked and appropriate during the inspection. All smoke detectors and carbon monoxide detectors were tested and found to be operational during the inspection. Water temperature in 3 of 3 resident bathrooms measured at 116 degrees and is within acceptable range of 105 to 120 degrees F. There was sufficient perishable and non-perishable foods located in the kitchen. Food menu was observed during the inspection. There are special provisions made for individuals with special dietary needs. Medications were centrally stored and locked. Medication Orders were reviewed. However, during a Medication Review, LPA observed that 2 out of 5 residents did not have medication available for use as outlined in Medication Orders by the physician. Furthermore, LPA learned that the one resident orders his own medication. However. based off the LIC 602 dated for March 22, 2022, (See LIC 812 dated for July 11, 2023 and named "LIC 602") the resident cannot manage own medication and needs assistance with ADLS (See LIC 809D). Cleaning products and other toxins are located in the garage that was locked and inaccessible to residents in care at the time of the inspection. There was a supply of Linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats. (Report continued on LIC 809C)
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 07/11/2023 03:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BETSY'S BOARD AND CARE
FACILITY NUMBER: 496803767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(a)
87355 Criminal Record Clearance

(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation of the Guardian Background Clearance, the licensee did not comply with the section cited above in 1 out of 1 persons do not have a background clearance which poses an immediate health, safety or personal rights risk to persons in care. ~~Civil Penalty Assessed~~
POC Due Date: 07/12/2023
Plan of Correction
1
2
3
4
Plan of Correction (POC) shall include a self-certification form LIC 9098, obtain background clearance for caregiver and provide a written statement on how future compliance with this regulation will be met.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BETSY'S BOARD AND CARE
FACILITY NUMBER: 496803767
VISIT DATE: 07/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A tour of all residents bedrooms were conducted, and bedrooms inspected have lighting and appropriate furnishing.

5 of 5 Resident records were reviewed during the Required 1 year inspection. However, during a resident file review, LPA observed that a resident did not have a reappraisal conducted in the year of 2023. LPA educated the licensee (See LIC 9102-Technical Violation). LPA learned that 2 of 2 staff records did not have appropriate training (See LIC 9102-Technical Violation). During a review of the staff records, LPA observed that staff did have First Aid/CPR was valid for all staff members that provide Care and Supervision to residents in care.

LPA reviewed the Emergency Disaster Plan with the Licensee. Quarterly Disaster Drill was conducted with all staff on duty on June 2023. LPA learned that the facility does not have the Infection Control Plan available for viewing. LPA educated the licensee regarding the importance of having this document retained at the facility for viewing when CCL comes (See LIC 9102-Technical Violation). Licensee states that she will submit a updated Infection Control Plan by July 17, 2023. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. LPA interviewed two staff. 3 out of 5 residents were interviewed, remainder of the residents were at doctors appointments.

LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308-Designation of Responsibility
LIC 400- Affidavit regarding Client Cash Resources
Updated facility sketch
Liability insurance
Control of Property
Register of clients

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Civil Penalty Assessed. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in additional civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Licensee.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/11/2023 03:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: BETSY'S BOARD AND CARE
FACILITY NUMBER: 496803767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation of resident medication orders, the licensee did not comply with the section cited above in 2 out of 5 residents did not have there prescribed medication as outlined in regulation which poses an immediate health, safety or personal rights risk to residents in care.
POC Due Date: 08/01/2023
Plan of Correction
1
2
3
4
Plan of Correction (POC) shall include the licensee reaching out via telephone to the doctors office to obtain the medication. In addition, the licensee shall fill out an LIC 9098-Self Certification understanding the regulation and also providing a statement on future compliance. Licensee requested for an extension.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4