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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804129
Report Date: 10/31/2024
Date Signed: 10/31/2024 03:46:19 PM

Document Has Been Signed on 10/31/2024 03:46 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:
10/31/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Staff Members, Gilbert Mishiame, Bibi Okoye and CEO/Licensee, Barrett AdamsTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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At approximately 9:30AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Staff Members, Gilbert Mishiame, and Bibi Okoye. Licensee/CEO, Barrett Adams, arrived during visit at approximately 10:15AM. 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, and 1 client attending Day Program via Zoom. LPA was also informed that there was two staff members on-site.

At approximately 9:30AM, LPA reviewed the Facility's Staff Roster. LPA found that Staff Member 1 (S1) was still not associated to the facility as required. Facility provided LPA with email correspondence with Guardian regarding S1's association to the facility. LPA provided Licensee/CEO with LIC9182, Transfer Request Form, in order to associate S1 to facility. LPA was provided with the paperwork and S1 will be associated to the facility roster at the Santa Rosa Regional Office. At approximately 10:00AM, LPA reviewed staff files, client files and client medications. Staff files had current First Aid and CPR certification. During File Review, LPA observed the following: Staff Member 2 (S2) did not have a health screening or proof of negative TB test on file (technical violation issued, LIC9102, regulation 80066(b)). LPA also observed the following items missing from client files:
  • Client 1 - missing admissions agreement, consent forms, personal rights, and pre-assessment
  • Client 2 - missing medical assessment, proof of negative TB test, personal rights, and pre-assessment
  • Client 3 - missing personal rights and pre-assessment
  • Client 4 - missing personal rights and pre-assessment
(deficiency cited, see LIC809D, regulation 80070(b)).

During medication review, LPA observed that the facility uses a written Medication Authorization Record (MAR) and a centrally stored log. LPA observed that some medications were not documented on the log as required. Per Licensee and staff members, facility has a nurse that fills out the centrally stored log every month (see technical violation, LIC9102, regulation 80075(k)(7). Facility does not manage/handle money for clients.

Continued on LIC809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2024
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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CINCO PALMAS
FACILITY NUMBER: 486804129
VISIT DATE: 10/31/2024
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Continued from LIC809

Per Licensee, they do not know when the facility last conducted an emergency disaster drill (deficiency cited, LIC809D, H&S Code 1565(c)). LPA also observed that facility does not have an evacuation chair on-site per Health and Safety Code (see technical violation, LIC9102, H&S Code 1565(f)(1)).
LPA and Licensee discussed the following:
  • Ensuring that a client assessment is conducted in addition to Regional Center assessments for clients prior to move in.
  • Ensuring that Individual Service Plans or Needs and Services Plans are conducted annually
  • Ensuring that medications are logged appropriately when received by the facility and that staff are trained by the facility nurse
  • Ensuring that Emergency disaster drills are conducted and documented at least quarterly
LPA provided blank copies of the following forms for facility: LIC627A, LIC627C, LIC613, LIC9182, LIC625

LPA also followed up on deficiencies that were cited during visit on 10/18/2024. Facility was to submit proof of in-service training by 10/28/2024. Per Administrator, Momo Duoa, an all staff training was scheduled for 11/04/2024. LPA discussed communicating with Licensing in the event a Plan of Correction is unable to be submitted by the agreed due date. Facility Administrator agreed to submit proof of documented training by 11/06/2024.

LPA requested the following documents to update facility file:
  • Designation of Facility Responsibility (LIC308)
  • Updated Emergency Disaster Plan (LIC 610D)
  • Updated Personnel Report (LIC 500)
  • Updated Liability Insurance
  • Active and Current Administrator Certificate
Documents to be submitted to Community Care Licensing (CCL) by due date of 11/30/2024.

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, LIC9102 (Technical Advisories/Violations), LIC811 (Confidential Names),Plan of Corrections, and Appeal Rights discussed and provided to CEO/Licensee. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Caitlynn Felias
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/31/2024 03:46 PM - It Cannot Be Edited


Created By: Caitlynn Felias On 10/31/2024 at 03:06 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: 10/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)
Client Records
(b) Each record must contain information including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, Licensee did not comply with the section cited above. LPA observed the following: 1 client did not have admissions agreement, consent forms, 1 client did not have medical assessment or proof of negative TB test, 3 of 4 clients missing personal rights and 4 of 4 clients did not have proof of pre-assessment. This poses a potential health and safety risk to clients in care.
POC Due Date: 11/11/2024
Plan of Correction
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Licensee to submit proof of missing documents to Community Care Licensing (CCL) by POC due date of 11/11/2024.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview conducted and observations made, Licensee did not comply with the section cited above. Licensee did not ensure that facility has conducted or documented an emergency disaster drill quarterly. This poses a potential health and safety risk to clients in care.
POC Due Date: 11/11/2024
Plan of Correction
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Licensee to submit a written plan stating how they will ensure that emergency disaster drills are conducted quarterly to CCL by POC due date of 11/11/2024.
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: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2024


LIC809 (FAS) - (06/04)
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