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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486804129
Report Date: 03/11/2025
Date Signed: 03/11/2025 01:45:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20241025173059
FACILITY NAME:CINCO PALMASFACILITY NUMBER:
486804129
ADMINISTRATOR:ADAMS, BARRETTFACILITY TYPE:
735
ADDRESS:332 OGDEN WAYTELEPHONE:
(707) 761-2587
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:4CENSUS: 3DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Licensee, Barrett Adams, and House Manager, Deborah Johnson-WhiteTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff did not report an incident involving resident in care as necessary
INVESTIGATION FINDINGS:
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At approximately 11:40AM, Licensing Program Analysts (LPAs) Felias and Deniz arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Licensee, Barrett Adams and House Manager, Deborah Johnson-White.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff did not report an incident involving resident in care as necessary.” Report received on 10/25/2024 alleged that facility did not report an incident to the Department in a timely manner.

Review of facility incident report showed that Client 1 (C1) had an incident that occurred on 10/19/2024. The Santa Rosa Regional Office (SRRO) received notification of this incident on 11/01/2024.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20241025173059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CINCO PALMAS
FACILITY NUMBER: 486804129
VISIT DATE: 03/11/2025
NARRATIVE
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Continued from LIC9099

Per Title 22 Regulations, incident reports must be submitted to CCL within seven (7) days of the incident occurring (deficiency cited, LIC809D, Regulation 80061(b)(1)(E)). Based on document review, this allegation is Substantiated. A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2024 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20241025173059

FACILITY NAME:CINCO PALMASFACILITY NUMBER:
486804129
ADMINISTRATOR:ADAMS, BARRETTFACILITY TYPE:
735
ADDRESS:332 OGDEN WAYTELEPHONE:
(707) 761-2587
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:4CENSUS: 3DATE:
03/11/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Licensee, Barrett Adams, and House Manager, Deborah Johnson-WhiteTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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At approximately 11:40AM, Licensing Program Analysts (LPAs) Felias and Deniz arrived unannounced to continue a Complaint Investigation regarding the above allegation and met with Licensee, Barrett Adams and House Manager, Deborah Johnson-White.

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Personal Rights.” Report received on 10/25/2024 alleged that Staff Member 1 (S1) called Client 1 (C1) “weak and pathetic” and shoved and slammed a chair into them.

Interviews conducted with staff and clients provided conflicting statements. Interview conducted with S1 denied the allegations and stated that they did not shove or slam a chair into C1. S1 also denied calling C1

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20241025173059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CINCO PALMAS
FACILITY NUMBER: 486804129
VISIT DATE: 03/11/2025
NARRATIVE
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Continued from LIC9099

weak and pathetic. Per S1, C1 was engaging in maladaptive behaviors such as verbal aggression, verbal threats, and property destruction. S1 stated that they used a chair to create space and distance between them and that C1 was redirected to their room. Interview conducted with C1 stated that S1 rammed a chair into their knees because they made verbal threats against S1. LPA conducted interviews with witnesses. 2 of 3 interviews conducted stated that S1 did not shove or slam a chair into C1 and that S1 did not call C1 weak and pathetic. 1 of 3 witness interviews stated that S1 shoved C1 and called them weak and pathetic.
Due to conflicting information provided during interviews, LPA is unable to determine if a violation of Title 22 Regulations has occurred. Therefore, the allegation is Unsubstantiated.

A finding that the complaint allegation is Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report discussed and provided to House Manager. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20241025173059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CINCO PALMAS
FACILITY NUMBER: 486804129
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/25/2025
Section Cited
CCR
80061(b)(1)(E)
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80061 Reporting Requirements:(b)...a written report.. shall be submitted...within seven days following the occurrence of such event.(1) Events reported shall include the following:(E) Any unusual incident or client absence which threatens the physical or emotional
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Licensee to conduct Incident Report training for all care staff. Inservice Training to include the following: Date, Training Topic, Name/Job Role, and Staff Signatures. Training to be submitted by POC due date of 03/25/2025.
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health or safety of any client. This requirement is not met as evidenced by: Based on record review, Licensee did not comply with the section cited above and did not submit reports to CCL as required. This poses a potential health and safety risk to residents in care.
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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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5