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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 06/17/2021
Date Signed: 06/17/2021 03:18:48 PM

Document Has Been Signed on 06/17/2021 03:18 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 7DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Staff, Noel MarayagTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPA) Victoria Willis and Erik Gonzalez Campos arrived unannounced to conduct an annual required inspection and were greeted by staff member Noel Marayag. Licensee/Administrator Bot Alicdan was available by phone. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPAs were asked to sign in but were not screened for COVID symptoms. LPAs initiated walk-through of the facility at 2:30 PM and observed COVID-19 posters throughout that included hand washing, cough etiquette etc. Facility was a comfortable temperature and exits were free from obstructions. Infection control has been discussed with residents and staff. Hand sanitizer is located throughout the facility for resident and staff use. Commonly touched surfaces are disinfected each shift and after every meal.

Common areas are set up for social distancing. Facility has a designated visitation area outside. Staff have completed PPE training but have not been N95 fit tested.

COVID mitigation plan was reviewed and approved during visit. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, face shields, gowns and hand sanitizer. Facility maintains a 30 day supply of medication.

Facility has 100 percent vaccination rate of staff and residents so may discontinue surveillance testing per PIN 21-28-ASC.

Continued on LIC809C

SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052
VISIT DATE: 06/17/2021
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Continued from LIC809

LPAs provided the following guidance;

  • Administrator to review PINs 21-17-ASC and 21-17.1-ASC with staff for new guidance regarding visitation, communal dining, etc.
  • Facility to screen all visitors upon entry to facility and document
  • Administrator to have staff N95 fit tested

Administrator and LPAs discussed their Emergency Disaster Plan.

No deficiencies cited during this inspection.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC809 (FAS) - (06/04)
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