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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 07/27/2022
Date Signed: 07/27/2022 03:29:59 PM

Document Has Been Signed on 07/27/2022 03:29 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: 17DATE:
07/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Robertson Cirineo (Staff)TIME COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Case Management visit 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 arrived at the facility and had their temperature checked and logged into a sign-in sheet.

On 7/18/22 LPA Cuadra received a call from Licensee, Josephine Credo to notify CCL that the facility obtained a building permit to start construction of more rooms to increase the capacity in facility vacant lot located at the back of the building. LPA requested written plan to be submitted to CCL prior to start the expected construction next week. On 7/22/22 Licensee submitted a copy of building permit from the City of Santa Rosa and written plan in how the facility will ensure the health and safety of residents in care while the construction occurs. Licensee also agrees to submit proof of contact with Fire Marshall regarding space modifications to ensure Fire Code Compliance.

During today's vist, LPA observed that construction zone in the back of the facility is not accessible to residents in care. There is a 6 foot secured fence around the construction area with signs of "DO NOT ENTER" posted. All materials and equipment were inside a locked storage inside the fence and inaccessible to residents in care. Construction crew members are present with brightly colored shirts and are only allowed in the construction area
unless needed and they are required to wear a mask at all times and show proof of Covid19 vaccination card. Staff is required to continuously remind and check all residents to make sure that they are not going to the construction site. All resident's responsible parties were notified.

Completion of the project is projected to be sometime in December of 2022.

No deficiencies noted at the time of the visit in the areas observed.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2022
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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