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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 08/09/2022
Date Signed: 08/15/2022 10:35:17 AM

Document Has Been Signed on 08/15/2022 10:35 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: 16DATE:
08/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:47 PM
MET WITH:Robertson Cirineo (Staff)TIME COMPLETED:
02:43 PM
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***AMENDED - Licensing Program Analyst (LPA) Cuadra arrived unannounced for the purpose of amending a case management report dated 8/9/2022 and citation issued the same date. The document requires amending because citation #80061(a)(1)(A) was issued in error by LPA and the amended document deletes reference to citation. LPA removed the citation in LIC809D as well.

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Case Management visit to this facility was greeted by staff, Robertson Cirineo who is the designated person on file to sign the report. LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet.
On 8/2/22 CCL received a SIR from Licensee Josephine Credo notifying CCl about resident (R1) who on 7/30/22 around 1:30am was noted by NOC staff while conducting their round check, resident was having shortness of breath and looking very pale, staff tried to waking up but R1 was not responding, their oxygen level was checked and it was very low between 60-79, 911 was called immediately, their responsible party (POA) was notified and resident was transported to the Hospital. POA called the Administrator to notify her that resident was not doing well, they couldn't insert any IV fluids due to having issues to find a good vain, R1 was declining very quickly due to respiratory and organ failure, it was decided to put resident on comfort care. On 8/3/22 LPA received a death report notifying CCL that R1 passed away on 7/31/22 around 7:45am. Per Licensee, they were notified by POA/conservator agreed that they will provide the death certificate to Licensee. However, death report was received at CCL 3 days later and not within 24 hours as stated in regulation. During today's visit, LPA confirmed with staff that R1 passed away on 7/31/22 and the facility did not notify to licensing agency within the agency's next working day during its normal business hours.
No deficiencies cited during today's inspection.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2022
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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Document Has Been Signed on 08/15/2022 10:35 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/10/2022 12:45 PM


Created By: Marisol Cuadra On 08/09/2022 at 01:19 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
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: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/26/2022
Section Cited
CCR
00000

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***AMENDED DOCUMENT - no deficiencies were cited.
80061 Reporting Requirements (a)Each licensee shall furnish to the licensing agency reports as required by the Dprt...a report shall be made to the licensing agency within the agency's next working day during its normal business hours....(1)(A) Death of any client from any cause. This requirement has not been met as evidence by:
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***AMENDED DOCUMENT - no deficiencies were cited
Facility to submit written statement acknowledging that they have read and understand "Reporting Requirements" by POC due date
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***AMENDED DOCUMENT - no deficiencies were cited.
Based on LPA’s records review and interviews conducted with staff, facility did not ensure that CCL was notified of death of R1 on 7/31/22. Facility submitted a death report for R1 on 8/3/22 which poses a potential health & safety risk to 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 Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


LIC809 (FAS) - (06/04)
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