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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804129
Report Date: 10/18/2024
Date Signed: 10/18/2024 04:08:28 PM

Document Has Been Signed on 10/18/2024 04:08 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:CINCO PALMASFACILITY NUMBER:
486804129
ADMINISTRATOR/
DIRECTOR:		ADAMS, BARRETTFACILITY TYPE:
735
ADDRESS:332 OGDEN WAYTELEPHONE:
(707) 761-2587
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY: 4CENSUS: 4DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:35 PM
MET WITH:Staff Member, Sarway Genesis, and CEO, Barrett AdamsTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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At approximately 12:35PM Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 Year visit and met with Staff Member, Sarway Genesis. CEO, Barrett Adams, arrived at approximately 1:15PM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 4 Ambulatory Clients. Upon arrival, LPA was informed that there were 4 clients in care with 1 client out of the facility attending Day Program. LPA was also informed that there was two staff members on-site.

At approximately 12:45PM, LPA reviewed the Facility's Staff Roster and found that Staff Member 1 (S1) was not associated to the facility as required (deficiency cited and civil penalty issued, see LIC809D and LIC421BG). Per conversation with Administrator, Momo Duoa, they have been in contact with Guardian regarding S1's association to the facility. Administrator also stated that they are responsible for ensuring that facility staff are background cleared and associated on Guardian. Administrator stated that they have proof of correspondence via email with Guardian, but was unable to provide it during visit. At approximately 1:00PM, LPA conducted a walk-though of the facility with Staff Member. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility had emergency lighting. Facility is a one story building with 4 Client bedrooms, 1 staff room, 3 bathrooms, and common areas. Facility has an Infection Control plan on file. 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 clients. Mattress pads were in place or available for client use. Hot water temperatures for all sinks in facility were within Title 22 regulations of 105 to 120 degrees Fahrenheit. Fire extinguishers were last inspected December 2022 (deficiency cited, see LIC809D, regulation 80020a))

During walkthrough, LPA observed the following hazards to be accessible: knife in drawer not designated for sharps, and cleaning solution under a client's bathroom sink (deficiency cited, see LIC809D, regulation 80087(g)). LPA also discussed ensuring that perishable food is labeled and dated appropriately. LPA, CEO, and Staff Member reviewed Guardian requirements, Title 22 Regulations, and Licensing expectations.
Administrator's Certificate for Barrett Adams (7029790735) was current with an expiration date of 08/17/2025.

Continued on LIC809C

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/18/2024
NARRATIVE
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Continued from LIC809

LPA unable to complete Annual Visit. Annual Continuation Visit to be conducted at a later date.

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.

***An immediate civil penalty assessment in the total amount of $100.00 has been issued for a violation of Health and Safety Code 1522(c)(1).*** (See LIC421BG)

Exit interview conducted. Copy of report, LIC809D, LIC421BG, Plan of Corrections, and Appeal Rights discussed and provided to CEO and Staff Member. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 10/18/2024 04:08 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/18/2024 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CINCO PALMAS
FACILITY NUMBER: 486804129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on obsersation, Licensee did not comply with the section cited above. LPA observed the following hazards to be accessible: knife in drawer not designated for sharps, and cleaning solution under a client's bathroom sink. This poses an immediate health and safety risk to clients in care.
POC Due Date: 10/19/2024
Plan of Correction
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Licensee to submit self-certification stating that training will be conducted reviewing regulation. Self-certification to be submitted by POC due date of 10/19/2024. In-service to include the following: Topic, Date, Length of Training, Job Role, Staff Names and Staff Signatures. Training to be submitted to CCL by POC Due Date of 10/28/2024.
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obsersation, Licensee did not comply with the section cited above. LPA observed 2 of 2 fire extinguishers to have not been serviced since December 2022. This poses an immediate health and safety risk to clients in care.
POC Due Date: 10/19/2024
Plan of Correction
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Licensee to submit a self-certification that they will service the fire extinguishers by POC due date of 10/19/2024. Licensee to submit proof of service to CCL by POC due date of 10/28/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 10/18/2024 04:08 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/18/2024 at 03:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: CINCO PALMAS
FACILITY NUMBER: 486804129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1522(c)(1)
General Provisions
(c)(1) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption from disqualification pursuant to subdivision (g) of this section or Section 1522.7 from the State Department of Social Services prior to employment, residence, or initial presence in the facility. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observations made, Licensee did not ensure that Staff Members 1, 2, and 3, (S1, S2, and S3) had the proper associations required to provide care at the facility. This poses an immediate health and safety risk to clients in care.
POC Due Date: 10/19/2024
Plan of Correction
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Licensee to submit a self-certification stating how they will ensure that individuals subject to a criminal record review receive proper clearance and are associated to facility prior to working per Title 22 regulations. Self Certification to be submitted by POC due date of 10/18/2024. Plan to be submitted by POC due date of 10/28/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Victoria Bertozzi
LICENSING EVALUATOR NAME:Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2024


LIC809 (FAS) - (06/04)
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