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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804129
Report Date: 10/05/2023
Date Signed: 10/05/2023 03:23:52 PM

Document Has Been Signed on 10/05/2023 03:23 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:CINCO PALMASFACILITY NUMBER:
486804129
ADMINISTRATOR:DUA, MOMO RFACILITY TYPE:
735
ADDRESS:332 OGDEN WAYTELEPHONE:
(707) 761-2587
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 0DATE:
10/05/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Barret Adams & Momo Duoa, Licensee ApplicantTIME COMPLETED:
03:30 PM
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On 10/5/2023 Licensing Program Analyst (LPA) Tobola conducted a pre-licensing inspection and was greeted by Licensee Applicant, Barret Adams and Administrator, Momo Duoa. This pre-licensing inspection is being conducted for an initial licensing. Fire Clearance has been approved for 4 ambulatory clients. Licensee Applicant is currently in partnership with North Bay Regional Center and in the process of finalizing vendorizing for client placement upon issue of license.

LPA conducted a tour and inspection of the indoor and outdoor portions of the facility. Facility was found to be clean and comfortable temperature with bedroom doors free from obstruction. Fire extinguishers throughout the facility were found to be last charged on 12/2/2022. Smoke detectors and carbon monoxide detectors were tested in common areas and client bedrooms all of which were found to be in working order. Emergency exits along the one side of the facility have appropriate hardware and found to be unobstructed. Water was measured between 106.3 & 117.5 degrees F in faucets used by clients which falls within regulation between 105 & 120 degrees F.

There was an ample supply of linens with appropriate bedding equipped in client rooms. An additional supply of hygiene, continence and paper products are located in a secured cabinet upstairs. Stairs and hallways are equipped with several night lights for accessibility and client bedrooms have appropriate furnishings. There is a sufficient amount of dishes and cooking supplies for client use with sharps and other hazardous items kept secured in designated drawer and under the kitchen sink. Cleaning products and other toxins and chemicals are kept out of client access and found secured in the garage and laundry room cabinets. LPA observed adequate supply of both perishable and non-perishable food sufficient for the 4 clients in care. The facility will be conducting weekly grocery replenishment with consideration to client preferences and dietary restrictions. A sample menu is also located on the refrigerator and indicates a healthy and balance set of meals for clients in care.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2023
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: CINCO PALMAS
FACILITY NUMBER: 486804129
VISIT DATE: 10/05/2023
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Medications are centrally stored and secured in locked cabinets located near the laundry room with Centrally Stored Medication Records and several other medication related forms on file. Client specified files including care plans, medical reports and dietary restrictions are located in a designated cabinet in the kitchen. There is also an office area located in the living room with all appropriate staffing records, program operation documentation and emergency disaster information. Licensing form templates pertaining to these sections have also been prepared. The facility has begun the hiring process for direct support staff and have appropriate criminal record and transfer forms readily available.

The backyard features a large yard and deck with seating for client outdoor use. The facility will be including additional recreational items based on client preference upon admission. Windows, screens and blinds are all found to be in good repair. Emergency evacuation maps and clear exit signs are observed posted at each exit door. Infection control plan has been updated and protocol infection prevention information has been posted at the entrance, common areas and bathrooms. A sign in sheet with proper screening devices and protection equipment were also observed at the front entrance. The facility and facility operation plan are found to be adequate and tour of the facility completed.

Licensee will be sending a copy of the updated liability insurance to CCLD. Component III orientation was conducted with the Licensee Applicant. The pre-licensing evaluation has been completed. License will be granted upon completion of a final review and approval from the Licensing Program Manager. This report was reviewed with applicant and a copy was provided to the Licensee.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
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