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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 08/15/2022
Date Signed: 08/15/2022 10:36:56 AM

Document Has Been Signed on 08/15/2022 10:36 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: 17DATE:
08/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Don Carrasco (staff)TIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit and get signatures on an amended report dated 8/9/22 and citation issued the same date. LPA met with staff Don Carrasco and explained the reason of the visit.

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. Report was amended and signed today, 8/15/2022.


No citations were issued during this visit.
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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