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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496803300
Report Date:
05/20/2024
Date Signed:
05/20/2024 02:30:49 PM
Document Has Been Signed on
05/20/2024 02:30 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 HOME
FACILITY NUMBER:
496803300
ADMINISTRATOR/
DIRECTOR:
ROBERTSON CIRINEO
FACILITY TYPE:
740
ADDRESS:
1217 LANCE DRIVE
TELEPHONE:
(707) 579-1739
CITY:
SANTA ROSA
STATE:
CA
ZIP CODE:
95401
CAPACITY:
23
CENSUS:
DATE:
05/20/2024
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
02:15 PM
MET WITH:
TIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analyst Mutialu arrive unannounced to amend the report dated 04/30/2024 to remove a civil penalty due to citation not being a repeat.
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
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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