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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803300
Report Date: 11/16/2023
Date Signed: 11/16/2023 10:28:14 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2023 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20231025080217
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:
11/16/2023
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Josephine Credo (Licensee)TIME COMPLETED:
10:43 AM
ALLEGATION(S):
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Staff did not respond to emergency personnel in a timely manner in the event of an emergency.
INVESTIGATION FINDINGS:
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Licensing Program Analyst Cuadra (LPA) arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Licensee, Josephine Credo.

There is an allegation regarding staff did not respond to emergency personnel in a timely manner in the event of an emergency. Per Reporting Party, on 10/10/23 it was noticed two bottles shaped like alcohol bottles with the labels off, and partially consumed in the closet on the shelf near the fire alarm. After staff took a long time to open the door to emergency personnel, there were concerns of staff possible consuming alcohol while on duty. Based on records review, LPA obtained records of incident #20230026355. Per incident, on 10/10/23 Santa Rosa Fire Department was dispatched to fire alarm call from the facility. Upon arrival of the emergency personnel at 6:54:32, they were ringing and banging on the door numerous times with no staff coming to unlock it for at least three minutes, until a resident in the front room was able to get up and come to the front door to open it.
Continues on LIC9099C...

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20231025080217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 11/16/2023
NARRATIVE
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Continued from LIC9099...

At 7:00:06 the incident was cancelled after they went to the enunciator and found a smoke B alarm, but no audible alarm, and it was confirmed on the main panel in the closet that all systems were normal.
Two staff showed up stating that they were in the back of the residence and did not hear anything. LPA conducted 10-day complaint inspection on 10/27/23, LPA/Administrator toured the facility and observed two bottles of alcohol antiseptic 80% topical solution hand sanitizer on the shelf of unlocked closet located in the hallway accessible to dementia residents in care. The deficiency will be addressed in a case management. LPA conducted interviews with Licensee. Per Licensee: “the monitoring system alarm of the new building goes off and most of the times it’s a false alarm, we were so used to having different departments like the Fire Department, The City, The Bay City sprinkler company visiting and randomly coming so if in case they happen to come, we do not consider it as an emergency”. However, the issue has been reported to the sprinkler company that installed the alarm, who came to check and inspect them and there should not be any false alarms. Based on LPA’s confidential interviews conducted with staff, it was confirmed that they did not hear any loud or fire alarm sound that will make them think that there was an emergency with any resident in care nor that emergency personnel were on the premises knocking on the door. The preponderance of evidence standard has been met, therefore the above allegation of staff did not respond to emergency personnel in a timely manner in the event of an emergency is found to be SUBSTANTIATED. The Health and Safety Code cited on the attached LIC 9099D. Appeal Rights Given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20231025080217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs. In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance/care… This requirement was not met as evidence by:
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Licensee to provide CCL the written facility policy and/or protocol regarding how resident's needs including residents with a diagnosis of dementia are going to been met when the staff are in the back of the building by POC due date.
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Based on interviews conducted with staff, the licensee did not ensure residents with a diagnosis of dementia needs were met timely as stated in their program plan due to the staff was not alerted that emergency personnel were knocking and ringing the doorbell in the front entrance of the facility, which poses an immediate risk to the health and safety of residents who has a diagnosis of dementia.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC9099 (FAS) - (06/04)
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