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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803300
Report Date: 09/24/2026
Date Signed: 09/24/2026 12:39:23 PM

Document Has Been Signed on 09/24/2026 12:39 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:
09/24/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:59 AM
MET WITH:Cirineo Robertson (Administrator)TIME VISIT/
INSPECTION COMPLETED:
12:54 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Plan of Correction (POC) visit. The purpose of this POC visit is to follow up on uncleared deficiencies cited on 08/27/2026, where LPA issued two citations for a violation of California Code of Regulation section 87405(a) and 87211 (a)(1)(A) with a plan of correction (POC), which are outstanding as of today.

During today's visit, administrator could not provide proof that incident hospitalization of resident (R1) on 8/22/26 or 8/25/26 and death report for resident (R2) on 8/13/26 were submitted to the department as well as care plans for residents (R3, R4, R5, R6, R7 & R8) were performed after been in non-compliance for more than 12 months as stated per regulation. LPA issued citation with new POC date.

***The facility will be assessed a civil penalty for $100 per day for the period of 09/19/2026 to 09/24/2026 totaling $600 per each deficiency not cleared by POC due date. The administrator acknowledges that civil penalties will continue to accrue $100 per day until the deficiency is corrected.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Appeal Rights Given.

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

Bethany Moellers
Marisol Cuadra
DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 09/24/2026 12:39 PM - It Cannot Be Edited


Created By: Marisol Cuadra On 09/24/2026 at 10:37 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: 09/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2026
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 administrator agreed to maintain required 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 10/05/26
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Based on LPAs'/licensee observation, interviews & 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. Administrator failed to clear citation from case management inspection on 8/27/26
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***The facility will be assessed a civil penalty for $100 per day for the period of 09/19/2026 to 09/24/2026 totaling $600.
Type B
10/05/2026
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. Administrator failed to clear citation from case management inspection on 8/27/26
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***The facility will be assessed a civil penalty for $100 per day for the period of 09/19/2026 to 09/24/2026 totaling $600.
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: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2026


LIC809 (FAS) - (06/04)
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