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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 08/27/2026
Date Signed: 08/27/2026 12:42:17 PM

Document Has Been Signed on 08/27/2026 12:42 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: 21DATE:
08/27/2026
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:50 AM
MET WITH:Robertson Cirineo (Administrator)TIME VISIT/
INSPECTION COMPLETED:
12:57 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance and met with administrator, Robertson Cirineo. LPA is following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 6/10/26:

- Administrator - Qualifications and Duties. The licensee did not maintain required facility documentation updated. During file review, LPA/Administrator observed that facility documented in resident's daily logs notes that resident (R1) was hospitalized on 8/22/26 due to change of condition and 8/25/26 due to catheter issues, then resident (R2) who was receiving hospice services passed away on 8/13/26, but records of incident reports submitted to the department were not found. Additionally, during annual visit conducted on 4/2/26, six out of ten residents' (R3, R4, R5, R6, R7 & R8) needed their care plans to be updated. On 6/18/26, Licensee submitted a written plan agreeing that they will ensure that all assigned administrators are qualified and responsible for maintaining up-to-date documentation. Furthermore, the licensee agreed to train and designate lead staff within each facility to assist the administrator and licensee by keeping all records organized and current. Based on records review and interviews with facility administrator and licensee, the facility has not updated residents' care plans and incident/death reports were not submitted to the department.

- Medication Management - Facility was pre-pouring residents' medications for more than 24 hour. Today, LPA conducted a spot check of medications, which were within compliance and the facility staff are not pre-pouring medications for more than 24 hour. Continued on LIC809C...
Bethany Moellers
Marisol Cuadra
DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2026
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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Document Has Been Signed on 08/27/2026 12:42 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 08/27/2026 at 11:43 AM
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: 08/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2026
Section Cited
CCR
87405(a)

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87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by:
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The licensee agrees to ensure that administrator will maintatin require facility documentation up-to-date including residents' medical assessments and care plans. Administrator will submit proof that residents' care plans were updated to CCL by POC due date.
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Based on LPAs'/licensee observation, interviews and record review, the licensee did not comply with the section cited above in not maintaining required facility documentation updated for residents in care, which poses a potential risk to the health, safety, or personal rights to persons in care.
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***civil penalties in the amount of $250 are issued due to repeated citation within 12 months.
Type B
09/18/2026
Section Cited
CCR87211(a)(1)(A)

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Type B - 87211 Reporting Requirements 87211 Reporting Requirements (a) Each licensee shall furnish...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within 7 days of the occurrence of any of the events specified in (A) through (D) below…This requirement has not been met as evidence by:
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Licensee agrees to ensure incidents are reported by regulation. Licensee agrees to review regulation 87211, submit incident/death reports and conduct training for all staff in reporting requirements. Evidence of completed training and incident/death reports to be submitted to CCL by POC date.
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Based on LPA’s/administrator records review and interviews, the licensee failed to notify the department within 7 days of occurrence about R1’s hospitalizations, and R2's death, which poses a potential risk to the health & safety of 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.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Marisol Cuadra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2026


LIC809 (FAS) - (06/04)
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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: 08/27/2026
NARRATIVE
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Continued from LIC809...

- Significant Delay in bringing LLC into compliance: The facility needs to submit a change of ownership application for all licensed facilities from a sole proprietorship to LLC, but its delayed due to not having an active LLC. Licensee acknowledges that they may not operate under their LLC because they are licensed under sole proprietorship. On 8/6/26, Licensee submitted written notification that their LLC is active. As of today, LPA learned that the licensee have contracted a consultant to assist with their application. LPA attempted to speak with licensee to obtain updated information, but LPA was unable to talk to licensee.

- Communication with Licensing Department: Discussion around their financial status after recent findings by the Department of Labor. Licensee acknowledges that they need to notify the Department immediately if they any concerns regarding financial distress.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. ***civil penalties in the amount of $250 are issued due to repeated citation within 12 months.

Exit interview conducted with administrator and copy of this report was given.

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

DATE: 08/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2026
LIC809 (FAS) - (06/04)
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