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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496803300
Report Date: 11/14/2025
Date Signed: 11/14/2025 11:07:37 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
09/02/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250902204313
FACILITY NAME:FIVE PALMS CARE HOMEFACILITY NUMBER:
496803300
ADMINISTRATOR:ROBERTSON CIRINEOFACILITY TYPE:
740
ADDRESS:1217 LANCE DRIVETELEPHONE:
(707) 579-1739
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:23CENSUS: 19DATE:
11/14/2025
UNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Josephine Credo (Licensee)TIME COMPLETED:
11:35 AM
ALLEGATION(S):
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-Staff did not prevent a resident in care from eloping from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Licensee, Josephine Credo.

Regarding the allegation of staff did not prevent a resident in care from eloping from the facility. According to the reporting party, on 08/31/25, resident (R1) left the facility without the staff knowing and went to the liquor store, then staff found R1 near the liquor store and they may have been vomiting. Although interviews conducted with Licensee, staff (S1) and R1 confirmed that R1 leaves the facility when they want to leave by just signing off the facility log, but on 8/31/25, R1 forgot to sign off the log, which resulted in S1 went to the bus stop to have R1 sign off the log before taking the bus to San Rafael where they visit a friend. Regarding the possibility of vomiting, Licensee stated that R1 has a habit of spitting that could lead others to think that they may have been vomiting.
Continue on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
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-20250902204313
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: 11/14/2025
NARRATIVE
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Continued from LIC9099...

Interviews conducted with R1 who has some communication challenges confirmed the above information by using a board to communicate with LPA, R1 denied vomiting or buying/drinking alcohol. According to R1, they bought 7up soda and chips only. Based on records review, R1’s physician report dated 7/25/25 revealed that R1 is not able to leave the facility unassisted due to major neuro-cognitive disease, needs transfer assistance – sit to stand supervision using front wheel walker, fall risk, special diet order low in sodium. R1’s care plan dated 7/15/25 has not been signed by R1 or their responsible party as indicated by regulation. Also, R1’s care plan does not reflect services needed including fall risk, transfers and special diet. LPA will cite deficiency found in a case management visit including reporting requirements, because the Licensee did not submit an incident report after learning of R1’s elopement. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. The Department will review the information obtained to determine if any further action is needed.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250902204313
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: 11/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/26/2025
Section Cited
HSC
1569.269(a)(6)
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Type B: 1569.269(a)(6) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:
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Licensee agrees to review the elopement plan for the facility addressing frequency of awol drills for staff. Facility to submit an LIC 9098 self-certification that Licensee has review elopement plan with frequency of awol drills for staff due by POC date.
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Based on LPA’s record review and interview the facility failed by allowing R1 leave the facility unassisted on 8/31/25, when R1’s physician report states that R1 is not able to leave the facility unassisted which poses an immediate health and safety risk to residents 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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3