486804129-9-3-2025-21-AS-VBEI-DL8NY8-20250905105216

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486804129
Report Date: 09/03/2025
Date Signed: 09/03/2025 12:35:50 PM

Unsubstantiated

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
06/18/2025 and conducted by Evaluator Ali Deniz

COMPLAINT CONTROL NUMBER: 21-AS-20250618113702

FACILITY NAME:	CINCO PALMAS		FACILITY NUMBER:	486804129
ADMINISTRATOR:	ADAMS, BARRETT		FACILITY TYPE:	735
ADDRESS:	332 OGDEN WAY		TELEPHONE:	(707) 761-2587
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	4	CENSUS: 1	DATE:	09/03/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Administrator, Deborah Johnson-White		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Staff threatened client with physical harm

INVESTIGATION FINDINGS:

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At approximately 12:15PM, Licensing Program Analysts (LPA) Deniz arrived unannounced to continue a complaint Investigation and delivered the findings regarding the above allegation and met with Administrator, Deborah Johnson-White

During the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegation was investigated, “Staff threatened client with physical harm.
On June 25, 2025, LPA conducted a tour of the facility. It was learned that Client C1 moved out of the facility two days after the alleged incident, which occurred on June 15, 2025. The LPA interviewed staff members S1 and S2, Client C1, and C1’s responsible party. Staff member S1 reported that they did not witness the incident. Staff member S2 denied threatening C1, stating that they were attempting to de-escalate the situation and protect themselves from potential harm. Client C1 acknowledged attempting to grab and throw an office chair at S2 during the incident and stated that they could not clearly recall what S2 said at the time.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250618113702

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: 09/03/2025

NARRATIVE

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Continued from LIC9099...

Based on the interviews that were conducted and the information received, there is no evidence to support that any staff member threatened any of the clients in care. LPA was unable to identify any clients in care being spoken to inappropriately or being threatened in any way.

Based on the statements received, observations made, and documents reviewed, A finding that the complaint allegation of Staff threatening resident is UNSUBSTANTIATED meaning that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.

Exit interview was conducted and a copy of this report was signed and given to the Administrator.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025

LIC9099 (FAS) - (06/04)

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