<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 04/30/2024
Date Signed: 04/30/2024 04:16:08 PM

Document Has Been Signed on 04/30/2024 04:16 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:FIVE PALMS CARE HOMEFACILITY NUMBER:
496803300
ADMINISTRATOR/
DIRECTOR:		ROBERTSON CIRINEOFACILITY TYPE:
740
ADDRESS:1217 LANCE DRIVETELEPHONE:
(707) 579-1739
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY: 23CENSUS: DATE:
04/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Robertson Cirine, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At approximately 9:00AM, Licensing Program Analysts (LPAs) Mutialu and Florio made an unannounced annual required inspection of this licensed senior care facility. LPAs met with Robertson Cirineo, Administrator and Josephine Credo, licensee arrived shortly after . At approximately 9:15AM, LPAs toured the building and grounds which was not found to be clean and in good repair. LPAs observed refrigerators and behind stove to be soiled and unclean, wall behind door in need of repair, paint and insect killer outside and accessible to clients. LPAs observed food not properly stored in the refrigerator and freezer, food was not covered and shown signs of freezer burn. LPAs observed 1 exit to be obstructed in C1 room, medical equipment and wheelchair found in front of emergency exit. LPAs observed open-faced heater in the hallway. Advised licensee open faced heaters are not allowed when caring for dementia clients.

All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. Advised licensee need updated activity calendar. The amount of perishable and nonperishable foods is with in regulation.Water temperature did not measure within regulation between 125.7 and 129 degrees F at faucets accessible to residents. Administrator lowered water heater temperature and water temperature was measured in regulation measuring between 105 and 120 degress F. Six out of six fire extinguishers inspected were charged. Smoke detectors/carbon monoxide signalling system passed fire inspection as of September 2023 and were found to be in working order. Facility has fire sprinklers throughout the facility and passed fire inspection as of April 2024. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

At approximately 10:45 AM, LPA reviewed 5 of 9 staff records. 4 of 5 records did not contain documentation of completed training records as required. Advised licensee all staff training needs to be up to date and completed by POC date of 05/07/2024. Evidence of current first aid and CPR training were current.
At approximately 12:15 PM, LPAs reviewed 5 of 15 resident records and found 2 of 5 residents did not have care plans. 1 of 5 records do not contain current and signed admission agreements. Advised licensee client records need to be kept up to date and training needs to be completed by POC date. Medication records are thorough.

Continued on 809C
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE: DATE: 04/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FIVE PALMS CARE HOME
FACILITY NUMBER: 496803300
VISIT DATE: 04/30/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Report Amended

Continued from 809

At approximately 1:00 PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 03/24/2024 for both day and night shifts.


Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
Evidence of Liability Insurance

Civil Penalties assessed for repeat violations for CCR 87307(d)(6) totalling $250

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Josephine Credo and Appeal rights were given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 04/30/2024 04:16 PM - It Cannot Be Edited


Created By: Stefanie Mutialu On 04/30/2024 at 02:40 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
, 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPAs and administrator found LPAs observed refrigerators and behind stove to be soiled and unclean also food not properly stored open in the refrigerator and freezer, food was not covered with signs of freezer burn, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
1
2
3
4
Licensee agrees to keep all food stored properly and staff cook to complete safe food and handling practices also to ensure all areas remain clean in kitchen and throughout the facility. Licensee to submit LIC9098 certifying that the plan of correction for training and food storage policy..
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in LPAs and administrator observed 1 exit to be obstructed in C1 room, medical equipment and wheelchair found in front of emergency exit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/01/2024
Plan of Correction
1
2
3
4
Licensee agrees to keep all passageways free from obstruction. Staff moved the medical equipment and wheelchairaway from exit door allowing passage. Licensee to submit LIC9098 certifying that the passageway will be kept free from obstructions.
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/30/2024 04:16 PM - It Cannot Be Edited


Created By: Stefanie Mutialu On 04/30/2024 at 02:40 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
, 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that LPAs and administrator observed paint and insect killer outside and accessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/01/2024
Plan of Correction
1
2
3
4
Licensee agrees to keep all toxins and harmfuk chemicals will be locked up and inaccesible to clients. Staff locked up all chemicals passage. . Licensee to submit LIC9098 certifying that all toxins, chemicals, and poisons will be locked up and/or inaccessible to clients.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 04/30/2024 04:16 PM - It Cannot Be Edited


Created By: Stefanie Mutialu On 04/30/2024 at 03:06 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
, 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: 04/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69


This requirement is not met as evidenced by: (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:
(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment.
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in that 4 of 5 staff records did not contain documentation of completed training records as required. Annual training for dementia, hospice, and medication annual training have not been completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/07/2024
Plan of Correction
1
2
3
4
Licensee agrees to ensure all training has been completed and will ensure all required training will be completed anually as required by regualtion. Licensee will provide proof of completion by POC and to submit LIC9098 certifying that all training is completed and will completed on time moving forward.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:Victoria Bertozzi
LICENSING EVALUATOR NAME:Stefanie Mutialu
LICENSING EVALUATOR SIGNATURE:
DATE: 04/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2024


LIC809 (FAS) - (06/04)
Page: 7 of 8