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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 07/01/2025
Date Signed: 07/01/2025 03:23:39 PM

Document Has Been Signed on 07/01/2025 03:23 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:BETSY'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
496800803
ADMINISTRATOR/
DIRECTOR:		LUNINGNING ALICDANFACILITY TYPE:
740
ADDRESS:1923 FALLEN LEAF DR.TELEPHONE:
(707) 545-1160
CITY:SANTA ROSASTATE: CAZIP CODE:
95405
CAPACITY: 6CENSUS: 3DATE:
07/01/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:41 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
03:38 PM
NARRATIVE
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Licensing Program Analyss (LPA) Christi Coppo arrived unannounced to conduct a Non-compliance and was greeted by caregiver.

On of 7/31/2024 licensee agreed to be on a Non-Compliance plan. The areas of concern were identified as:
· Administrator Duties and Plan of Operation
· Staff Training
· Resident and staff records
· Resident Care and Personal Rights
· Insufficient Staffing
· Failure to clear deficiencies timely
· Medication Management
· Failure to follow through with TSP

Licensee was to ensure the following:
· Follow through with responding to and participating with the Technical Support Program
· Ensure compliance with areas including, but not limited to, staff training records, maintaining staff and resident records and pre-pouring of medication.
· Ensuring personal rights of residents in care and ensuring resident needs are met.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/01/2025
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Continued from 809,,,
Today, LPA toured facility and found it to be clean and at a comfortable temperature.

As pertains to Administrator duties and qualifications: on 6/19/25 LPA Frank notified Administrator Luninging Alicdan of the following: They said your application to recertify your Administrators certificate was missing hours. They said they tried to contact you several times with no response. As such the application has been closed. Please contact them immediately as your facilities currently don’t have a certified Administrator. As of today, CCL has not received a response from Administrator and their certificate is still expired. With LPA present Admin called Admin cert unit but was unable to reach an agent. Admin explained she owed $10 and sent that $10 on 6/24/25, but has yet to hear anything else (deficiency cited, see 800D).

As pertains to staff training: S2 and S3 do not have the required number of hours of training completed (deficiency cited, see 809D).

As pertains to resident and staff records: All staff current in CPR/1st Aid. All staff have Health Screen present with TB clearance. All required resident documentation present.

As pertains to Resident Care and Personal Rights: LPA visited room #4 and found it to be clean and free from incontinence odors. LPA visited all rooms of residents and found them to be free of incontinence odors as well. Facility overall free from incontinence odors.

As pertains to inadequate staffing: LPA reviewed Guardian roster and found all active employees associated to the facility. LPA reviewed LIC500 and found at least 2 people on shift for day shift, evening shift, and NOC shift.

As pertains to failure to clear deficiencies timely: Licensee has not had any outstanding deficiencies to clear in a timely manner, so licensee found to be in compliance with clearing deficiencies timely.

As pertains to medication management: LPA did spot check of medication and verified that facility is no longer pre-pouring medications.

As pertains to following through with TSP: licensee has followed through with TSP.

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 Administrator. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/01/2025 03:23 PM - It Cannot Be Edited


Created By: Christi Coppo On 07/01/2025 at 02:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2025
Section Cited
HSC
1569.625(b)(2)

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§1569.625 Staff training; legislative findings; contents (b)(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually...

This requirement is not met as evidenced by:
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Facility to submit current and completed training certificates in the requried number of hours by plan of correction due date.
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Based on LPA and caregiver observations, the licensee did not comply with the section cited above in that S2 and S3 did not have the required number of training hours completed, which poses a potential health, safety or personal rights risk to persons in care.
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Type B
07/22/2025
Section Cited
CCR87405(a)

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87405(a) Administrator - Qualifications and Duties(a) All facilities shall have a qualified and currently certified administrator. This requirement not met as evidenced by:
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Administrator to submit copy of current Administrator certificate.
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Administrator does not have an actively current Administrator certificate. This poses an immediate health, safety or personal rights risk to residents
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2025


LIC809 (FAS) - (06/04)
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