Facility Evaluation Report

At approximately 8:40 AM, Licensing Program Analyst (LPA) Robert arrived unannounced to conduct a 1-Year Required Visit. Administrator Edward Alicdan, arrived at approximately 9:15 AM. Licensee Luningning Alicdan arrived at 11:25 AM. Betsy's II RCFE is Licensed as a Residential Care Facility for the Elderly (RCFE). The facility is a large single story ranch house. The facility has a plan of operation for dementia care and programming on file. The facility has an approved fire clearance and total capacity for thirteen (13) residents of which eleven (11) residents may be non-ambulatory, and two (2) residents may be bedridden. Facility has an approved hospice waiver for three (3) residents. Facility has approval to have a locked perimeter. Upon arrival, LPA was informed that there were eight (8) Residents in care. LPA reviewed the Facility's Staff Roster and observed that staff member S1 was not associated to the facility in the Guardian Background Check system as required per regulations. The facility will be cited for this deficiency and a Civil Penalty of $500 will assessed for this violation. All other staff members were observed to be background cleared and associated to the facility per regulation.

At approximately 9:10 AM, LPA toured the facility. All exits were clear and unobstructed. Facility fire extinguishers were last serviced and tagged in June, 2025. The automatic sprinkler system was serviced in 11/2025. The facility's fire alarm system was inspected and tagged in 5/2026. The facility was sufficiently lighted. LPA inspected eight (8) resident bedrooms and found all to have sufficient lighting and furnishings as required per Title 22 Regulations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for residents. Facility has an infection control plan as required. The facility has a required emergency disaster plan. The facility is conducting fire and emergency drills quarterly. The last disaster drill was conducted on 3/31/2026. Continued on 809-C...