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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 10/27/2023
Date Signed: 10/27/2023 11:53:40 AM


Document Has Been Signed on 10/27/2023 11:53 AM - 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:FIVE PALMS CARE HOMEFACILITY NUMBER:
496803300
ADMINISTRATOR:CREDO, JOSEPHFACILITY TYPE:
740
ADDRESS:1217 LANCE DRIVETELEPHONE:
(707) 579-1739
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:23CENSUS: 14DATE:
10/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:Robertson Cirineo (Staff)TIME COMPLETED:
12:08 PM
NARRATIVE
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Licensing Program Analyst(LPA) Cuadra is conducting a case management visit and met with staff Robertson Cirineo. Licensee Josephine Credo was not able to come to the facility, but gave authorization to staff to sign the report.

During today's complaint visit, LPA/staff learned through observation that exit door located in resident's room#8 was blocked with a recliner. Staff immediately removed recliner obstructing the exit from the passageway. Also, LPA/staff observed that temperature in the back building where resident's rooms #8-12 are located in the back of the building was not comfortable. LPA learned through interviews with staff that the facility is kept warm as needed by using portable heaters in each resident's room, because the main heater for the back of the building is not working properly. LPA/staff observed that each resident room (room#8-12) have a small working portable heater that was on distributing heat all around the room.

The deficiencies cited are unrelated to the complaint investigation.

Exit interview conducted with staff and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
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 2


Document Has Been Signed on 10/27/2023 11:53 AM - It Cannot Be Edited

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: FIVE PALMS CARE HOME
FACILITY NUMBER: 496803300

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2023
Section Cited
CCR
87307(d)(6)

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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement has not been met as evidence by:
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Licensee agrees to keep all passageways free from obstruction. Staff moved the recliner away from exit door allowing passage. Licensee to submit LIC9098 certifying that the passageway will be kept free from obstructions.
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Based on LPA's/staff observation that exit door located in resident's room#8 was blocked with a recliner. Staff immediately removed recliner obstructing the exit from the passageway, which poses an immediate risk to the health and safety of residents in care.
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Type A
10/28/2023
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee agrees to provide proof of service that heater in the back is working properly by POC due date.
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Based on LPA's/staff observations and interviews with Licensee the heater in the back of the building is not working properly, which is an immediate risk to the health and safety of 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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2