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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 03/10/2022
Date Signed: 03/10/2022 12:56:28 PM

Document Has Been Signed on 03/10/2022 12:56 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: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: 15DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Robertson Cirineo (staff)TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility was greeted by staff, Robertson Cirineo. Licensee, Josephine Credo was not able to come but was available by phone and gave authorization to staff to sign the report. LPA conducted a Risk Assessment with staff. LPA/Licensee reviewed over the phone PIN 22-05, 22-06, 22-07 & 22-09.

LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/staff conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer were observed in the common area of the facility. Facility bathroom are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least three times a day. Facility is able to accommodate a single room for each resident that needs to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols and N-95 fit tested. Staff and residents are being monitored daily and results are documented on a binder. Facility maintains a 30 day supply of medication. Facility has 100% vaccinated rate for all staff and residents have received boosters. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Residents receive indoor visitation with their families and facility performs antigen tests to visitors as well as screening, documenting for symptoms and tracking purposes. Facility has submitted their Covid Mitigation Plan and approved on 1/4/22. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields and hand sanitizer. PPE supplies are located in an accessible place for staff.

Licensee agreed to provide copies of the following by 3/24/22: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), Lease agreement, Liability insurance & Emergency Disaster Plan (LIC610E). No deficiencies cited during this inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2022
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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