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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800803
Report Date: 08/06/2025
Date Signed: 08/06/2025 01:15:36 PM

Document Has Been Signed on 08/06/2025 01:15 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:
08/06/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:54 AM
MET WITH:Luningning Alicdan, licenseeTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyss (LPA) Christi Coppo arrived unannounced to conduct a POC Case Management and was greeted by caregiver. Licensee Luningning Alicdan arrived later.

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

On 7/1/25 LPA conducted a Non-compliance visit at the facility. Two areas of concern for which the licensee is on non-compliance were identified as being deficient: Administrator qualification and duties and staff training. During this visit, a citation was issued for deficiency of Health and Safety Code (HSC) 1569.625(b)(2) as staff (S2 and S3) did not have the annual required number of staff training hours completed . A plan of correction was issued for licensee to have staff S2 and S3 complete the required

Continued on 809C....
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2025
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: 08/06/2025
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Continued from 809...

number of annual training hours. The plan of correction due date by which the training was to be completed was 7/22/25. Licensee submitted the plan of correction for HSC1569.625(b)(2) by the plan of correction due date. Deficiency has been cleared.

At the same visit on 7/1/25, LPA also issued a citation for deficiency of regulation 87465 Administrator qualifications and duties, as licensee does not have a current Administrator certificate. A plan of correction was issued, requiring Administrator to submit copy of their current Administrator certificate. Plan of correction due date was 7/22/25. As of today, licensee still does not have an active Administrator certificate nor have they hired a qualified administrator. So, deficiency is being re-cited today (see 809D).

Due to logistic reasons, licensee will not be able to obtain an administrator certificate until 12/2025. LPA and licensee discussed plan to hire an administrator. Licensee has enrolled two [2] of her staff in the Administrator certificate classes, both of which begin on 8/19/25. LPA advised that the facility cannot be without an administrator while waiting for the staff to complete their training courses. Licensee advised LPA they are having an extremely difficult time finding a qualified RCFE administrator, but that they have not ceased efforts. Licensee is in consistent contact with LPA concerning this deficiency of regulation.

LPA advised licensee that having consistent deficiencies pertaining to the areas of concern for which they were placed on non-compliance may lead to further action by CCL, such as civil penalties and/or revoking their license.

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: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/06/2025 01:15 PM - It Cannot Be Edited


Created By: Christi Coppo On 08/06/2025 at 12:44 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: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2025
Section Cited
CCR
87405(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: Based on LPA and and licensee interview and record review, the licensee did not comply with the section cited above in that
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Licensee to submit to CCL Adminsitrator paperwork for Administrator candidate once candidate is selected. Paperwork to include: LIC215, LIC500, LIC308, LIC501, detailed employment/education history, and copy of Admin certificate
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Administrator does not have an actively current Administrator certificate or Administrator, which 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: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2025


LIC809 (FAS) - (06/04)
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