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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 04/02/2026
Date Signed: 04/02/2026 02:55:48 PM

Document Has Been Signed on 04/02/2026 02:55 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
CCLD Regional Office, 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: 20DATE:
04/02/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Josephine Credo (Licensee)TIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Robertson Cirineo, Administrator; Josephine Credo, Licensee arrived later.

Once inside the facility, LPA/Administrator observed construction crew members present in the hallway near lateral exit making loud noise replacing the hallway flooring, while there were seven residents in the adjacent living room playing bingo, there were no posters alerting residents about construction zone, all materials and equipment were inside unlocked and accessible to residents in care. According to Administrator, construction crew members are only allowed in the construction area. Upon Licensee's arrival, LPA inquired about expectation of completion of the project and was told that expected time to be 4/3/26. However, Licensee did not report to the Department about the flooring replacement project and staff present were not observed reminding residents continuously to make sure that they are not going through the construction area. LPA requested written plan to be submitted to CCL and proof that resident's responsible parties were notified. The facility is not ensuring the health and safety of residents in care while the construction occurs. There are currently residents with a diagnosis of Dementia. Licensee instructed all staff present to frequently remind residents to be cautious when passing by flooring replacement area.

At approximately 1:00pm LPA/Licensee observed water temperature in resident's bathroom measured at 158.5, 158.5, 160.7 degrees F in the main building and 108.1 degrees F in the back building which are not within allowable range of 105 to 120 degrees F. Licensee printed signs to post in faucets used by residents and adjusted water heater. Continue on LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/02/2026
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: FIVE PALMS CARE HOME
FACILITY NUMBER: 496803300
VISIT DATE: 04/02/2026
NARRATIVE
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Continued from LIC809...
LPA/Licensee toured the facility and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Extra hygiene products and linens were available. Bathrooms had required bath mats and grab bars. Cabinets containing cleaning supplies and other items that could pose a risk were locked. Five out of five fire extinguisher were last inspected July, 2025. Facility has a centralized smoke detector system that was last tested September 8, 2025. Carbon monoxide detector was tested and operational. Exit doors have auditory alert system and were functional at time of visit. Medications were centrally stored and locked. Facility has a generator to supply power during an outage. Facility has enough food supplies including water to operate for more than 72 hours during an emergency. Last Emergency Disaster Drill was conducted on 3/26/26. Required postings were observed. Annual fees current. Hospice waiver approved for four residents.

LPA initiated file review at 10:00 am. Five staff files and ten resident files were reviewed. Staff files reviewed have required First Aid and CPR certificates and training hours complete. However, LPA had a conversation with the Licensee because three out of five staff (S1, S2 & S3) presented a CPR/1st aid certificate dated today, where two out of the three staff were observed the morning assisting residents in care with activities of daily living and not attending to such training. According to Licensee, staff have already taken the training prior to today's date, but the certificate reflects today's date because today is the day when payment was submitted. Seven out of ten (R1, R2, R3, R4, R5, R6 & R7) needs and services plan needs to be updated. One out of ten residents (R1) needs an updated medical assessment. Administrator Certificate for Administrator, Robertson Cirineo, 7012701740, expires on 10/3/26. Medications and medication records were reviewed. There was no Register of Clients (LIC90920) form on file as stated per regulation.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Licensee and copy of report was provided.

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Marisol Cuadra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/02/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2026
LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 04/02/2026 02:55 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/02/2026 at 02:24 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: 04/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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
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Based on LPA's/Licensee observation, record review and interview with Licensee, the licensee did not comply with the section cited above by not making provisions to ensure construction area was free of hazards which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee agreed to submit written plan to CCL and proof that resident's responsible parties were notified by POC due date 4/3/26.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Licensee observed water temperature in resident's bathroom measured at 158.5, 158.5, 160.7 degrees F in the main building which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee/Administrator to ensure hot water is maintain between 105F and no higher than 120F. Licensee turned down the hot water heater and will monitor for a period of one week ensuring hot water is within regulation. Licensee agreed to submit self-certification form ensuring that water measures will be kept within regulation to clear the deficiency by POC due date 4/3/26.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/02/2026 02:55 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/02/2026 at 02:24 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: 04/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, records review and interviews with Administrator, the facility failed to leave medication in original container pre-pouring into more than 24 hour container which poses an immediate health and safety risk to resident in care.
POC Due Date: 04/03/2026
Plan of Correction
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Licensee/Administrator agrees to stop pre-pouring medication greater than a 24 hr period. Submit self certification (LIC9098) of above to CCL by POC 4/3/2026.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2026


LIC809 (FAS) - (06/04)
Page: 5 of 8
Document Has Been Signed on 04/02/2026 02:55 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/02/2026 at 02:24 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: 04/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in having construction crew members present in the hallway near lateral exit making loud noise and having unlocked materials including sharps replacing the hallway flooring, while there were seven residents in the adjacent living room playing bingo, there were no posters alerting residents about construction zone, Licensee did not notify the Department and resident's responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Licensee agrees to submit a written plan to CCL and proof that resident's responsible parties were notified by POC due date 4/17/26.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in seven out of ten residents (R1, R2, R3, R4, R5, R6 & R7) care plans were not updated within the last 12 months which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Licensee agrees to arrange a meeting with parties outlined in regulation 87463(a) and update appraisals for noted residents. Licensee will submit self certification (LIC9098) that all appraisals have been updated per regulation 87463 by POC due date, 4/17/26 to clear the citation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2026


LIC809 (FAS) - (06/04)
Page: 6 of 8
Document Has Been Signed on 04/02/2026 02:55 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 04/02/2026 at 02:24 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: 04/02/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87508(a)
Register of Residents
(a) The licensee shall ensure that a current register of all residents in the facility is maintained and contains the following updated information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not having a current register of resident's form on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/17/2026
Plan of Correction
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Facility to submit a current Register of Residents to CCL by POC date in order to clear the deficiency and agrees to keep it current going forward in compliance with regulation 87508(a)
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/02/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/02/2026


LIC809 (FAS) - (06/04)
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