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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496800803
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:41:06 AM

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
07/05/2024 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20240705095753
FACILITY NAME:BETSY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
496800803
ADMINISTRATOR:LUNINGNING ALICDANFACILITY TYPE:
740
ADDRESS:1923 FALLEN LEAF DR.TELEPHONE:
(707) 545-1160
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY:6CENSUS: DATE:
07/31/2024
UNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:Alicdan Luningning, licenseeTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff left resident in soiled depends/linens for an extended period of time
INVESTIGATION FINDINGS:
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At approximately 9:30am, Licensing Program Analyst (LPA) Christi Coppo and Alicdan Luningning met at the Santa Rosa Regional Office and LPA delivered findings regarding the above allegation.

Complaint alleges staff left resident in soiled depends/linens for an extended period of time. Reporting party was informed that resident at facility was found by a witness in soiled briefs and linens, appearing that the soiling occurred overnight. Photographic evidence of soiling was provided to CCL during CCL investigation. LPA interviewed witness that observed resident in soiled briefs on a prior occasion and LPA observed resident in soiled briefs when conducting investigation. LPA also observed resident’s room to have a strong smell of urine when conducting the annual inspection at facility in February of 2024. In February, licensee explained that the reason for the strong urine smell was due to resident frequently urinating.

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

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
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-20240705095753
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 RESIDENTIAL CARE HOME
FACILITY NUMBER: 496800803
VISIT DATE: 07/31/2024
NARRATIVE
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Continued from 9099...

Facility caregiver stated to interviewed witnesses, that resident frequently urinates. Witnesses interviewed explained that licensee advised them of the same thing, that this resident frequently urinates so they cannot always be kept clean and dry.

LPA interviewed licensee and caregiver at facility, both explained that resident frequently urinates and is on an incontinence brief changing schedule. Resident is on a changing schedule as they require medication previous to their being changed because they experience pain when being repositioned. Caregiver explained that the resident gets changed by our schedule which is: between 9am and 10am after morning shift caregiver serves all other residents’ breakfast, at noon if resident needs it, at 4pm, at 8pm, then at 10pm or midnight depending on when afternoon caregiver leaves the facility. So, between 10pm or midnight until 9am the next day resident is not changed.

Per review of resident’s hospice care plan, resident is to be repositioned every 3 to 4 hours for pressure relief. Hospice care plan also specifies that resident is to have an incontinence check every 3 to 4 hours to mitigate skin breakdown. However, per interview with licensee and caregiver, resident is not attended to for anywhere between 9 and 12 hours overnight. Therefore, based on LPA's observations, photographic evidence, 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 LIC9099D.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20240705095753
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 RESIDENTIAL CARE HOME
FACILITY NUMBER: 496800803
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2024
Section Cited
CCR
87625(b)(2)
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87625(b)(2) Managed Incontinence (b) In addition to Section 87611...the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night
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Facility to update care plan for resident per hospice care plan and send LIC500 showing sufficient staff to meet care and incontinence needs.
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This requirement is not met as evidenced by: Based on evidence obtained during investigation, the licensee did not comply with the section cited above in that licensee did not ensure incontinence needs were met per hospice care plan, 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3