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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 09/15/2025
Date Signed: 09/15/2025 02:25:54 PM

Document Has Been Signed on 09/15/2025 02:25 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:
09/15/2025
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Josephine CredoTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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An informal meeting was conducted today in the Santa Rosa Regional Office. Present at the meeting were Licensing Program Managers Bethany Moellers and Victoria Bertozzi (via Microsoft Teams), Licensing Program Analysts Christi Coppo, Robert Frank, Marisol Cuadra (via Microsoft Teams) and Licensee of the facility, Josephine Credo.

On 9/10/25, The Licensee submitted written communication via email to the Department requesting information regarding change of ownership. Currently, LIC309 Administrative Organization form indicates that these facilities are in a sole proprietorship. According to the Licensee, their accountant has advised them to switch it to a limited liability company (LLC) where Josephine Credo will be the Licensee in LLC of these facilities. The purpose of the office meeting was to address concerns and discuss the change of ownership for Five Palms Care Home #496803300, Valley View Care Home #496803362 and Chanate Care Home #496801588 in which Josephine Credo is the identified Licensee. As of today’s date, a new application has not been submitted to the Department. License acknowledges that they are responsible for the operation until the new application is approved and issued. The Licensee agrees to provide documentation to ensure control of property. The Licensee confirms understanding that the current license is not transferable and an application is required to be submitted to the Department for change of ownership. Also, areas of concern regarding training materials that are not updated and reporting requirements. The current options discussed during today’s office meeting are the following:

-Submit a change of ownership application with new corporation or LLC to the Centralized Application Bureau (CAB) for the three facilities by not later than xxx, 2025. CAB contact information was provided.

-Also, it was agreed to review reporting requirements regulation (87211), and they will conduct all staff training to address ongoing reporting requirement issues by not later than xxx, 2025.

-The Licensee agrees to review current training materials and trainers been used to train staff and they will upgrade them if needed.

No deficiencies cited during today's meeting.



Copy of report discussed and provided to Administrator Credo. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 09/15/2025
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...Continued from 809

before proceeding with Centralized Application Bureau. LPM Bertozzi advised to update their Plan of Operation. To be included in the new Plan of Operation licensee will need to reference what training will be provided to staff. Submit a change of ownership application with new corporation or LLC to the Centralized Application Bureau (CAB) for the three facilities by not later than 10/13/25. CAB contact information was provided.
-LPAs reviewed reporting requirements regulation (87211), and gave copy to LLC.

-The Licensee agrees to submit current training materials and a plan of how she will utilize the new vendor for staff training. Licensee to submit course contents from new training vendor, by no later than 9/22/25.

LPM Moellers offered TSP, licensee agreed to participate.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Appeal Rights Given. Exit interview conducted with Licensee and a copy of this report was given

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Robert Frank
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 09/15/2025 02:25 PM - It Cannot Be Edited


Created By: Robert Frank On 09/15/2025 at 02:05 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: 09/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/13/2025
Section Cited
CCR
87109(b)

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87109 Transferability of License
(b)The licensee shall notify the licensing agency and all residents receiving services, or their representatives, in writing as soon as possible and in all cases at least thirty (30) days prior to the transfer of the property or business... This requirement is not met as evidenced by:
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Licensee will provide proof to Community Care Licensing that an application has been submitted to the Centrailized Application Bureau by POC due date of 10/13/2025.
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Based on interview & record review, the licensee did not comply with the section cited above in the licensee did not notify Community Care Licensing within thirty (30) business days of the transfer of the facility to a Limited Liability Corporation which poses a potential health, safety or personal rights risk to persons 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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Robert Frank
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2025


LIC809 (FAS) - (06/04)
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