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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496802052
Report Date: 06/09/2022
Date Signed: 06/09/2022 02:50:18 PM

Document Has Been Signed on 06/09/2022 02:50 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 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: 10DATE:
06/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Licensee, Luningning "Bot" AlicdanTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee, Luningning "Bot" Alicdan. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors of the mask and vaccination verification policy per Provider Information Notice (PIN) 21-40-ASC. Once inside, LPA observed a screening station near the entrance. LPA initiated a walk-through of the facility at around 1:00pm and observed the following: Facility has COVID-19 posters throughout that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected three times per day and after use. Facility recently discontinued documenting staff and resident daily temperatures. LPA directed them to continue documenting temperatures and symptoms.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Licensee continues to train on infection control and PPE but have not been N95 fit tested. LPA gave Licensee information to have her staff fit tested. LPA and Licensee discussed visitation and activities.

Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has some PPE but LPA directed Licensee to obtain additional PPE. Facility maintains a 30 day supply of medication. Facility had a fire inspection April 2022 by the local fire department and they tested sprinklers and fire detectors. Fire Extinguishers are charged but have not been serviced in the last year. Licensee needed clarification regarding the tag on the fire extinguisher that shows when servicing is due. LPA also checked the Carbon Monoxide detector and it was functional.

Continued on LIC809C

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE: DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/09/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: BETSY'S II RCFE
FACILITY NUMBER: 496802052
VISIT DATE: 06/09/2022
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Licensee and LPA discussed their Emergency Disaster Plan and the Infection Control Plan. Infection Control Plan is due 6/30/2022.

Licensee/Administrator to submit updates of the following documents by 07/09/2022:
LIC 308 Designated Administrator
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan (if there are changes)
Copy of proof of property ownership once escrow closes
Liability Insurance

No deficiencies cited during this inspection.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Willis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022
LIC809 (FAS) - (06/04)
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