Five Palms Care Home

Type of visit: Case Management - Legal/Non-compliance

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... 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.the state’s words, verbatim · CDSS document, Aug 27, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 18, 2026

87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: 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.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: 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. ***civil penalties in the amount of $250 are issued due to repeated citation within 12 months.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(1)(A) · Plan of correction due date: Sep 18, 2026

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: 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.the state’s words, verbatim · CDSS document, Aug 27, 2026

Plan of correction: 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.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management-other to follow up on updated information regarding the status of their change of ownership application and was greeted by staff Wennie Fernandez. Licensee, Josephine Credo was not able to come to the facility, but she was available by phone and gave authorization to staff to sign the report. On 9/15/25, there was an informal office meeting at the Santa Rosa Regional Office with the Department's Licensing Program Managers, Licensing Program Analysts and the Licensee of the facility Josephine Credo. During the meeting, it was discussed a change of ownership for all licensed facilities (Five Palms Care Home #496803300, Valley View Care Home #496803362 and Chanate Care Home #496801588) from a sole proprietorship to an LLC. To date, the Change of Ownership is delayed due to not having a valid LLC. During today's visit, LPA learned that Franchise Tax Board (FTB) instructed the Licensee to call back next week by Wednesday they might have an update to provide them regarding their LLC validation. No deficiencies cited during today's visit. Exit interview was conducted with Licensee via phone and copy of this report was given.the state’s words, verbatim · CDSS document, Jul 31, 2026

Type of visit: Office

A Non-Compliance Conference (NCC) was conducted today in the Santa Rosa Regional Office. Present in the meeting were: Regional Manager (RM) Carla Nuti-Martinez, Licensing Program Manager (LPM) Victoria Bertozzi, Licensing Program Analysts (LPAs) Christi Coppo, Marisol Cuadra and Licensee Josephine Credo. The purpose of today's office meeting was to discuss areas of concern in the facility operation identified by the department and placing Valley View Care Home, Five Palms Care Home and Chanate Care Home on a Non-Compliance Conference (NCC) plan. Parties present during the meeting agreed to an NCC plan to bring the facilities into compliance. An Office meeting was held 9/15/2025 to discuss a change of ownership for all licensed facilities from a sole proprietorship to an LLC. To date, the Change of Ownership is delayed due to not having a valid LLC. Items addressed during the meeting include, but are not limited to: Significant Delay in bringing LLC into compliance therefore delaying the Change in Ownership Recent findings by the Department of Labor Medication Management Record keeping (Administrator) Parties present during the meeting agreed to an NCC plan for 2 years to bring the facility into compliance. Health and Safety Code 1569.686 was given to Licensee notification of specified events; department initiation of compliance plan, noncompliance conference, or other appropriate action; penalties; exception was printed and given to licensee. The licensee understand they may not operate under their LLC as they are licensed under sole proprietorship There was a discussion about Technical Support Program (TSP) referral and Licensee agreed to be referred to the TSP program and referral will be submitted. Deficiencies are cited from the California Code of Regulations (CCR), and/or the Health and Safety Code. Failure to correct the cited deficiency, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Exit interview conducted with licensee and a copy of this report given.the state’s words, verbatim · CDSS document, Jun 10, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Jun 17, 2026

87405 Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. This requirement is not met as evidenced by: 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, which poses a potential risk to the health, safety, or personal rights to persons in care.the state’s words, verbatim · CDSS document, Jun 10, 2026

Plan of correction: The licensee agrees to submit written plan agreeing to comply with administrator qualifications including accountable staff that will be responsible of maintaining facility documentation and medication updated to clear the citation by POC due date of 6/17/2026.

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Marisol Cuadra arrived unannounced to conduct a Case Management investigation and was greeted by staff, Licensee, Josephine Credo arrived later. On 5/12/26 the department received an email from the licensee pertaining to resident (R1). On 5/11/26, R1 was victim of a hit-and-run accident that resulted in R1's passed away. According to Licensee, on 5/11/26 at approximately 12:30pm, R1 informed a lead staff member about their intentions to travel to downtown Santa Rosa and planning on returning in the evening, R1 signed the facility sign-in/sign-out form log at 12:45pm, then at approximately 2:45pm - 3:00 PM, staff noticed unusual traffic congestion on street due to the sirens in the neighborhood and reports of a person in a wheelchair being struck by a vehicle, staff became concerned and one staff member went to investigate along with Administrator, when they approached the scene identified R1's wheelchair and confirmed that the resident had passed away. The Administrator identified themselves to the police and notified responsible parties. As of today, the facility has not received an official update from the Santa Rosa Police Department case# 26-4898. During today's visit, LPA conducted interviews, reviewed documents, and received copies of documents. Based on records review, LPA was provided with sign-in/sign-out form including R1's sign off time and most recent R1's physician report (LIC602) dated 4/14/2026. According to R1's physician indicated that they were not at risk of harm due to their cognitive condition when leaving the facility unsupervised; Therefore, R1 was permitted to leave the facility unassisted. Licensee agreed to obtain R1's Death Certificate to provide to CCL once received. No deficiencies cited during this visit. Exit interview conducted with Licensee and copy of this report was given.the state’s words, verbatim · CDSS document, May 13, 2026

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Apr 2, 2026

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

At approximately 8:35 AM, Licensing Program Analyst (LPA) Robert Frank, arrived unannounced to conduct a Case Management Visit and met with Administrator, Robertson Cirineo. The purpose of the visit is to deliver an Order for an Immediate Exclusion for staff member S1 from all facilities. Per the Immediate Exclusion notice, Staff Member S1 cannot be allowed to work, be present and/or live in a Community Care Licensing (CCL) licensed facility, or have contact with residents in any residential facility or child day care facility licensed by the California Department of Social Services. Therefore, the Department orders the facility to remove S1 from any contact with residents and not allow this employee to be physically present in the facility. Administrator informed LPA that S1 has not worked at the facility for two (2) years. Administrator stated they understood the notice. No Deficiencies Cited during visit. Exit interview conducted. Copy of report and LIC-811 Confidential Names, discussed and provided to Administrator Cirineo. Signature on form confirms receipt of documents.the state’s words, verbatim · CDSS document, Mar 5, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management-other to follow up on a pending death certificate for resident (R1) and updated information regarding the status of their change of ownership application and met with Administrator Robinson Cirineo. On 9/15/25, there was an informal office meeting at the Santa Rosa Regional Office with the Department's Licensing Program Managers, Licensing Program Analysts and the Licensee of the facility Josephine Credo. During the meeting it was agreed that the Licensee will be submitting a change of ownership application with new corporation or LLC to the Centralized Application Bureau (CAB) for the three facilities (Five Palms Care Home #496803300, Valley View Care Home #496803362 and Chanate Care Home #496801588) by not later than 10/13/25. On 10/13/25, the Licensee requested a proof of correction (POC) extension until 11/10/25 due to the submission of application packet for J&J Assisted Living, LLC was facing two-sensitive external delays, one external delay was with the documentation submitted to the Franchise Tax Board (FTB) and their application were not complete. On 10/14/25, LPM Bertozzi approved a POC extension to 10/31/25, but a new extension was requested and LPM granted a new extension date to 11/7/25. However, the Licensee requested an new extension date indicating that the FTB process will take about four to six weeks to process it and CAB advised the Licensee to not submit an application until their FTB issue was resolved. Continued on LIC809C... Continued from LIC809... Furthermore, Licensee agreed to LPM's Bertozzi instructions to provide an update every Friday by the close of business (5:00pm) until the payment has been processed. However, the Licensee has not been submitting an update to the Department weekly as agreed to LPM Bertozzi. On 1/7/26, it was the last documented written communication submitted by the Licensee to the Department providing an update regarding the status of their FTB filing for their LLC is still pending. During today's visit, LPA Cuadra requested an update of their FTB process staus. Per Licensee, on 1/27/26 FTB processed their payment and are currently reviewing their documentation, which it could take up to 10 to 14 days for their website to update and show their LLC as active. LPA inquired about the lack of weekly communication with the Department to notify about current status as instructed by LPM. The Licensee did not provide a reason for the delay of communication with the Department, but agreed to submit weekly updates on Fridays as previously agreed. Regarding the status of death certificate for R1, the Licensee indicated that they are still expecting the certificate to be obtained by R1's family, but they agreed to follow up and submit to CCL as agreed as soon as they received it. No deficiencies cited during today's visit. Exit interview conducted with Administrator and a copy of this report was giventhe state’s words, verbatim · CDSS document, Feb 3, 2026

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra arrived unannounced to follow up on a self-incident/death report and met with Licensee, Josephine Credo. The purpose of this case management inspection is to follow up on a self incident/death report submitted to Community Care Licensing (CCL) on 12/04/25. According to incident report sent in by the facility, on 12/3/25, resident R1 was found around 6:45am while staff was conducting their morning round with their right leg dangling, so staff assisted R1 to reposition their leg and remind them not to attempt to get up unassisted, R1 acknowledged and went back to sleep, then staff returned around 7:15am, but R1 was unresponsive, had shallow breathing, so staff called 911 immediately, the operator instructed them to initiate cardiopulmonary resuscitation until paramedics arrived, but R1 passed away at 8:07am. Police officers called the coroner and responsible parties were notified by the facility. During today's visit, LPA learned through file review of R1's physician report that they had a history of chronic heart failure. LPA have requested R1's death certificate to be submitted for review and it was agreed that they will submit it once receive it. The Department will be reviewing documents once received to investigate the unexpected death of resident due to R1 was not receiving hospice services and death was unexpected. No deficiencies cited during today's visit. Exit interview conducted with Licensee and a copy of this report was given.the state’s words, verbatim · CDSS document, Dec 11, 2025

Allegation investigated: -Staff did not prevent a resident in care from eloping from the facility.

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 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.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 21-AS-20250902204313

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.269(a)(6) · Plan of correction due date: Nov 26, 2025

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: 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.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: 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.

Allegation investigated: -Personal Rights.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Josephine Credo, Licensee. The allegation is about facility violating resident's personal rights. According to the reporting party, the facility is not allowing visitors for resident (R1), but acknowledges that in one occasion they were able to visit R1 at the facility, but they observed that R1 was depressed due to not been assisted with hearing aids with no one knowing sign language around them. Based on records review, the facility provided sign-in log confirmed that R1 has been receiving regular visits from various outside parties. Also, R1’s physician report dated 7/25/25 indicates that R1 is deaf and does not indicate the need for assistive devices. Based on interviews conducted with R1 using a small board to communicate with them, it revealed that they prefer not to receive visits from a couple individuals and regarding hearing aids, they expressed: “I don’t need them”. Continues on LIC9099C... Unsubstantiated Continued from LIC9099... Interviews conducted by LPA with staff (S1 & S2) confirmed that the facility allows all residents to receive visitors during visiting hours, but when a resident refuses to receive visits there is nothing, they can do about it. Interviews conducted by LPA with outside parties (I1 & I2) confirmed that they have been able to visit R1 without any issues or restrictions. Based on interviews and records review, LPA is unable to determine if a violation of personal rights occurred at a prior date. A finding that the allegation of facility violating resident's personal rights is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Nov 14, 2025 · control 21-AS-20251027101955

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with Josephine Credo, Licensee. LPA learned through records review and interviews conducted on 9/9/25 with Licensee that the facility failed to complete R1’s care plan reflecting services needed including fall risk, transfers and special diet as stated in R1’s physician report (LIC602). During the investigation LPA reviewed records obtained from the facility and determined that elopement incident that occurred on 8/31/25 was not reported by the facility to the Department. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months. 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.the state’s words, verbatim · CDSS document, Nov 14, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87457(c) · Plan of correction due date: Nov 26, 2025

Type B - 87457 Pre-Admission Appraisal 87457 Pre-Admission Appraisal: (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria… This requirement is not met as evidenced by: Based on records reviewed, Licensee did not complete an evaluation of resident’s condition prior to admission and keep it in the file which poses a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: Licensee will submit a plan of how they will ensure resident’s pre-admission appraisals are completed prior to resident’s admission including their individual service needs. Plan of future compliance to be submitted to CCL by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87211(a)(2) · Plan of correction due date: Nov 26, 2025

Type B: 87211(a)(2) 87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports..: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This rerquirement was not met as evidence by: Based on LPA’s record review and interview, the facility failed to submit an incident report when R1 went AWOL on 8/31/25 which possessed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 14, 2025

Plan of correction: Licensee agrees to review regulations pertaining to reporting requirements. Licensee agrees to submit a plan to ensure incident reports are submitted to CCL and responsible party within 7 days, submit plan to CCL by POC. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months.

Type of visit: POC

Licensing Program Analyst (LPA) Cuadra arrived unannounced , to conduct a Plan of Correction (POC) visit. On 10/17/2025, LPA issued two citations for a violation of California Code of Regulation section 87211(a)(2) and 87506 (d)(e) with a plan of correction (POC), which are outstanding as of today. One out two POC called for the Licensee to provide training to all Staff reviewing the Regulation: 87211 (a)(2) Reporting Requirements. In-service Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date of 10/31/25. During today's visit, Licensee provided proof of correction for citation 87211 (a)(2)- Deficiency cleared from case management visit 10/17/2025. Copies of documents obtained. The second POC called for the Licensee to review regulation 87506 regarding resident records and retain at the facility resident's records to be available to the licensing agency for review as stated per regulation and Licensee agreed to submit documents requested by POC due date 10/31/25. Today, Licensee could not provide proof to clear citation 87506 (d)(e) and documentation for residents (R1) including Physician's Report (LIC602), daily chart notes and care plan were not available for LPA to review. ***The facility will be assessed a civil penalty for $100 per day for the period of 10/31/2025 to 11/6/2025 totaling $700. The civil penalty 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. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given. Exit interview with Licensee and copy of this report was given.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Cuadra arrived unannounced to follow up on a self reported death incident and met with Caregiver, Robertson Cirineo. The purpose of this case management inspection is to follow up on a self-report death report submitted to Community Care Licensing (CCL) on 10/15/25. According to death report sent in by the facility, resident R1 was rushed to Kaiser Emergency Room on 10/8/25 at about 7am due to vomiting, R1 reported to be in pain, and black/tarry appearance. Responsible parties were notified. According to death report dated 10/14/25, R1 was diagnosed with renal failure and passed away on 10/9/25 at 1:45pm. During today's visit, LPA conducted file review and spoke with Administrator. File review indicated that R1 had a previous hospitalization back on 9/21/25 and returned to the facility within two days on 9/23/25 where they were seen due to abdominal pain, chronic ulcer of left heel -unspecified depth (chronic), pressure ulcer of sacrum-unspecified stage. The hospitalization was reported to CCL, but the unstageable wound was not reported to CCL. After visit summary indicates follow up visit for wound care on 9/25/25. Also, R1 had history of urinary tract infections (UTI). According to Administrator, R1 only had a small red dot in their sacrum, but ignores the reason why Licensee did not report it to CCL. LPA have requested to the Administrator R1's death certificate to be submitted for review and it was agreed that they will submit it once receive it. Also, LPA was unable to review R1's records including Physician's Report, chart notes and care plan, because records were not available at the facility for LPA's review. The Department will be reviewing documents once received to investigate the unexpected death of resident due to R1 was not receiving hospice services and death was unexpected. Deficiencies are cited from the California Code of Regulations (CCRs), Title 22 (Div- 6), Chpt 8 & the H&S 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 Administrator and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(2) · Plan of correction due date: Oct 31, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports..: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This rerquirement was not met as evidence by: Based on LPA's observations, records review and interview with Administrator, the facility did not notify CCL within 24 hours of occurreence of R1's death which poses a potential risk to the health & safety of the residents.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: Licensee to provide training to all Staff reviewing the Regulation: 87211 Reporting Requirements. Inservice Training to include the following information: Date of Training, Training Topics, Job Role, Staff Names and Signatures. Training to be submitted to CCL for review and approval by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(d)(e) · Plan of correction due date: Oct 31, 2025

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, & copy upon demand during normal business hours…(e) Original records...shall be retained for a min of 3 years following termination of service to the resident. This requirement was not met as evidence by: Based on LPA's record review and interview with Licensee, the facility did not have available R1's records when requested by CCL, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 17, 2025

Plan of correction: Licensee agreed to review regulation 87506 regarding resident records and will retain at the facility resident's records to be available to the licensing agency for review as stated per regulation. Licensee will submit documents requested by POC due date.

Type of visit: Office

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. ...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 giventhe state’s words, verbatim · CDSS document, Sep 15, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87109(b) · Plan of correction due date: Oct 13, 2025

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: 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.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: 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.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Case Management visit to this facility was greeted by Administrator, Robertson Cirineo. On 5/5/25 the facility fire clearance was updated and approved for 23 bedridden residents' rooms including the room additions made to their floor plan located at the back of the building. During today's visit, LPA toured the new rooms to ensure the health and safety of residents in care, but the residents have not been relocated as of today yet. However, LPA observed that additional rooms are properly furnished per regulation. LPA/Licensee have a conversation regarding Dementia regulation changes and provided resources including physician's report (LIC602A) for their review. No deficiencies noted at the time of the visit in the areas observed. Exit interview was conducted with Administrator and copy of this report was given.the state’s words, verbatim · CDSS document, Jun 17, 2025

Allegation investigated: -Staff yell at resident. -Staff raised arm to resident in a threatening manor.

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. The Department received an allegation of staff yell at resident, staff raised arm to resident in a threatening manner. Per Reporting party, resident (R1) has mentioned that staff (last name unknown) yells at them and swung their arm at R1 like if they were going to hit the resident. Based on interviews conducted by LPA with residents (R1, R2, R3, R4, R5, R6, R7 & R8) and staff (S1, S2 & S3) revealed some conflicting information regarding who mostly yells at the house are some residents (no names were provided), but their statements were consistent about no witnessed or observation of any staff yelling, raising their voice or their arms in a threatening manner to the residents in care. Residents indicated that they feel safe at the home, and they are not afraid of people at the house. Staff denied yelling and raising their arms at residents including R1. Continue on LIC9099C... Unsubstantiated Continued from LIC9099... Based on records review, R1 did not seek medical treatment after the alleged incident nor appear to have any bruising or marks indicating any physical abuse. Also, LPA obtained police records # SR250210082 concluded that the suspected abuser was another resident and not staff. A finding that the complaint allegation occurs of staff yell at resident, staff raised arm to resident in a threatening manner is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 17, 2025 · control 21-AS-20250121095733

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct an Annual Required Inspection and met with Robertson Cirineo, Administrator; Josephine Credo, Licensee arrived later. There are currently residents with a diagnosis of Dementia. Required postings were observed. Annual fees current. LPA/Administrator initiated a tour of the facility at 9:00am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in resident's bathroom measured at 107.4, 105, 117.1 and 118 degrees F which are within allowable range of 105 to 120 degrees F. 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, 2024. Facility has a centralized smoke detector system that was last tested July 10, 2024. 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. LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility did not has enough food supplies to operate for more than 72 hours during an emergency (Technical violation issued). Last Emergency Disaster Drill was conducted on 2/4/25. At approximate 9:15am LPA/Administrator observed three oranges, seven bananas and twenty six apples, which is not adequate supply of perishables for at least two days. However, one week of non-perishable foods was observed in stock. LPA have a discussion with Licensee regarding the importance to have an adequate supply of fruits and vegetables as indicated per regulation. Continued on LIC809C... Continued from LIC809... LPA initiated file review at 10:00 am. Three staff files and eight resident files were reviewed. Staff files reviewed have required First Aid and CPR certificates and training hours complete. Six out of eight (R1, R2, R3, R4, R5 & R6) needs and services plan needs to be updated. The facility is a one story building and has an approved fire clearance dated February 9, 2011 that allows for 23 non-ambulatory residents and no bedridden resident. However, during records review one (R4) out eight residents have a bedridden status and are occupying room #7, which are not cleared by the Fire Department as bedridden rooms. Licensee is operating outside the limitation of the license by accepting a bedridden resident in a non-ambulatory room. LPA/Licensee discussed the issue about R4 to provide the option to submit a request to obtain updated physician's report, because according to the Licensee, R4 is not bedridden and they will obtain an updated physicians' report (LIC602). During the visit, LPA spoke with R4 who was observed and expressed that they are not fully bedridden and they are in agreement to obtain an updated medical assessment. Administrator Certificate for Administrator, Robertson Cirineo, 6042225740, expires on 10/3/27. Medications and medication records were reviewed. On 3/7/25 LPA Cuadra was notified by the Licensee that the project of building additional rooms located at the back of the building that will be used for single/shared occupancy for the same capacity of residents is complete and requested an updated fire clearance to get approval for space modifications performed to ensure fire code compliance. On 4/1/25, LPA Cuadra received a call from fire inspector requesting a 30 day extension to approve fire clearance due to some issues involving both parties regarding fire sprinkler installation. During today's visit, LPA toured the additional rooms involved in the updated fire clearance did not observe any evidence of resident's belongings in area. Administrator to submit updates of the following documents by 4/24/2025: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500) and Liability Insurance Certificate. 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 Josephine Credo and A copy of report was provided.the state’s words, verbatim · CDSS document, Apr 17, 2025

The state marks this report as 5 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Allegation investigated: Resident was sexually abused by staff.

Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Robertson Cirineo, Administrator. It was alleged that resident was sexually abused by staff. During the course of this investigation, The Department investigator conducted interviews with staff, residents and other witnesses, and reviewed records associated to the involved resident (R1). Based on interviews conducted and records obtained the investigation revealed that staff (S1) has touched “the front of their.” R1 did not feel that S1’s intentions were “sexual” or that they “crossed the line.” R1 stated S1 called them beautiful and other complimentary names. Resident (R2) stated that on one occasion a male staff “grabbed both of their wrists,” to “silence their hands.” R2 also shared that they heard comments about rape from a female Caregiver. Staff and residents who were interviewed did not witness or experience inappropriate behavior from S1 or staff (S2) who were the only night staff around the time of the alleged sexual abuse. Continued on LIC9099C... Unsubstantiated Continued from LIC9099... Licensee stated that staff are directed to ask the resident, or announce what they are going to do, prior to washing private areas of resident’s bodies. According to the Licensee, S1 had worked at the facility for about four to five years and R1’s allegation was the first complaint of sexual abuse that a resident had ever shared about S1. S1 adamantly denied the allegation to Licensee. Attempts to contact S1 were unsuccessful. According to staff, S1 did not have a cell phone, and they lived at the facility during their employment; therefore, no current address was available. Attempts to contact S1 at two former addresses were also unsuccessful. A finding that the complaint allegation occurs of resident was sexually abused by staff is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.the state’s words, verbatim · CDSS document, Dec 17, 2024 · control 21-AS-20240903132941

Type of visit: Case Management - Other

Licensing Program Analyst Mutialu arrive unannounced to amend the report dated 04/30/2024 to remove a civil penalty due to citation not being a repeat.the state’s words, verbatim · CDSS document, May 20, 2024

Type of visit: Required - 1 Year

At approximately 9:00AM, Licensing Program Analysts (LPAs) Mutialu and Florio made an unannounced annual required inspection of this licensed senior care facility. LPAs met with Robertson Cirineo, Administrator and Josephine Credo, licensee arrived shortly after . At approximately 9:15AM, LPAs toured the building and grounds which was not found to be clean and in good repair. LPAs observed refrigerators and behind stove to be soiled and unclean, wall behind door in need of repair, paint and insect killer outside and accessible to clients. LPAs observed food not properly stored in the refrigerator and freezer, food was not covered and shown signs of freezer burn. LPAs observed 1 exit to be obstructed in C1 room, medical equipment and wheelchair found in front of emergency exit. LPAs observed open-faced heater in the hallway. Advised licensee open faced heaters are not allowed when caring for dementia clients. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed activity supplies for resident use. Advised licensee need updated activity calendar. The amount of perishable and nonperishable foods is with in regulation.Water temperature did not measure within regulation between 125.7 and 129 degrees F at faucets accessible to residents. Administrator lowered water heater temperature and water temperature was measured in regulation measuring between 105 and 120 degress F. Six out of six fire extinguishers inspected were charged. Smoke detectors/carbon monoxide signalling system passed fire inspection as of September 2023 and were found to be in working order. Facility has fire sprinklers throughout the facility and passed fire inspection as of April 2024. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure. At approximately 10:45 AM, LPA reviewed 5 of 9 staff records. 4 of 5 records did not contain documentation of completed training records as required. Advised licensee all staff training needs to be up to date and completed by POC date of 05/07/2024. Evidence of current first aid and CPR training were current. At approximately 12:15 PM, LPAs reviewed 5 of 15 resident records and found 2 of 5 residents did not have care plans. 1 of 5 records do not contain current and signed admission agreements. Advised licensee client records need to be kept up to date and training needs to be completed by POC date. Medication records are thorough. Continued on 809C Report Amended Continued from 809 At approximately 1:00 PM, LPA reviewed the facility emergency disaster plan with staff. Facility has a generator to supply power during an outage. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 03/24/2024 for both day and night shifts. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report Evidence of Liability Insurance Civil Penalties assessed for repeat violations for CCR 87307(d)(6) totalling $250 Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. This report was reviewed with Josephine Credo and Appeal rights were given.the state’s words, verbatim · CDSS document, Apr 30, 2024

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Staff did not respond to emergency personnel in a timely manner in the event of an emergency.

Licensing Program Analyst Cuadra (LPA) arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Licensee, Josephine Credo. There is an allegation regarding staff did not respond to emergency personnel in a timely manner in the event of an emergency. Per Reporting Party, on 10/10/23 it was noticed two bottles shaped like alcohol bottles with the labels off, and partially consumed in the closet on the shelf near the fire alarm. After staff took a long time to open the door to emergency personnel, there were concerns of staff possible consuming alcohol while on duty. Based on records review, LPA obtained records of incident #20230026355. Per incident, on 10/10/23 Santa Rosa Fire Department was dispatched to fire alarm call from the facility. Upon arrival of the emergency personnel at 6:54:32, they were ringing and banging on the door numerous times with no staff coming to unlock it for at least three minutes, until a resident in the front room was able to get up and come to the front door to open it. Continues on LIC9099C... Substantiated Continued from LIC9099... At 7:00:06 the incident was cancelled after they went to the enunciator and found a smoke B alarm, but no audible alarm, and it was confirmed on the main panel in the closet that all systems were normal. Two staff showed up stating that they were in the back of the residence and did not hear anything. LPA conducted 10-day complaint inspection on 10/27/23, LPA/Administrator toured the facility and observed two bottles of alcohol antiseptic 80% topical solution hand sanitizer on the shelf of unlocked closet located in the hallway accessible to dementia residents in care. The deficiency will be addressed in a case management. LPA conducted interviews with Licensee. Per Licensee: “the monitoring system alarm of the new building goes off and most of the times it’s a false alarm, we were so used to having different departments like the Fire Department, The City, The Bay City sprinkler company visiting and randomly coming so if in case they happen to come, we do not consider it as an emergency”. However, the issue has been reported to the sprinkler company that installed the alarm, who came to check and inspect them and there should not be any false alarms. Based on LPA’s confidential interviews conducted with staff, it was confirmed that they did not hear any loud or fire alarm sound that will make them think that there was an emergency with any resident in care nor that emergency personnel were on the premises knocking on the door. The preponderance of evidence standard has been met, therefore the above allegation of staff did not respond to emergency personnel in a timely manner in the event of an emergency is found to be SUBSTANTIATED. The Health and Safety Code cited on the attached LIC 9099D. Appeal Rights Given.the state’s words, verbatim · CDSS document, Nov 16, 2023 · control 21-AS-20231025080217

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Nov 17, 2023

87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, & competent to provide the services necessary to meet resident needs. In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance/care… This requirement was not met as evidence by: Based on interviews conducted with staff, the licensee did not ensure residents with a diagnosis of dementia needs were met timely as stated in their program plan due to the staff was not alerted that emergency personnel were knocking and ringing the doorbell in the front entrance of the facility, which poses an immediate risk to the health and safety of residents who has a diagnosis of dementia.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: Licensee to provide CCL the written facility policy and/or protocol regarding how resident's needs including residents with a diagnosis of dementia are going to been met when the staff are in the back of the building by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Cuadra arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with Licensee, Josephine Credo. On 10/27/23, LPA/Administrator toured the facility and observed two bottles of alcohol antiseptic 80% topical solution hand sanitizer on the shelf of unlocked closet located in the hallway accessible to residents in care. Based on records review of facility dementia program plan dated 02/10/2011, the facility shall ensure that toxic substances including alcohol, cleaning supplies and disinfectants are inaccessible to residents with dementia. Therefore, the facility did not ensure to store two bottles of hand sanitizer inaccessible to residents with a diagnosis of dementia. 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.the state’s words, verbatim · CDSS document, Nov 16, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(f)(2) · Plan of correction due date: Nov 17, 2023

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) alcohol…cleaning supplies and disinfectants. This requirement was not met, as evidenced by: Based on observations made by LPA/Administrator, the facility staff did not ensure that two bottles of alcohol antiseptic 80% topical solution hand sanitizer were on the shelf of unlocked closet located in the hallway accessible to residents in care, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Nov 16, 2023

Plan of correction: Facility to send in written plan they understand regulation and how it will be followed. The facility will remove items that should not be accessible by POC due date.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst(LPA) Cuadra is conducting a case management visit and met with staff Robertson Cirineo. Licensee Josephine Credo was not able to come to the facility, but gave authorization to staff to sign the report. During today's complaint visit, LPA/staff learned through observation that exit door located in resident's room#8 was blocked with a recliner. Staff immediately removed recliner obstructing the exit from the passageway. Also, LPA/staff observed that temperature in the back building where resident's rooms #8-12 are located in the back of the building was not comfortable. LPA learned through interviews with staff that the facility is kept warm as needed by using portable heaters in each resident's room, because the main heater for the back of the building is not working properly. LPA/staff observed that each resident room (room#8-12) have a small working portable heater that was on distributing heat all around the room. The deficiencies cited are unrelated to the complaint investigation. Exit interview conducted with staff and a copy of this report was given.the state’s words, verbatim · CDSS document, Oct 27, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(6) · Plan of correction due date: Oct 28, 2023

87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement has not been met as evidence by: Based on LPA's/staff observation that exit door located in resident's room#8 was blocked with a recliner. Staff immediately removed recliner obstructing the exit from the passageway, which poses an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Licensee agrees to keep all passageways free from obstruction. Staff moved the recliner away from exit door allowing passage. Licensee to submit LIC9098 certifying that the passageway will be kept free from obstructions.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87303(a) · Plan of correction due date: Oct 28, 2023

87303 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. Based on LPA's/staff observations and interviews with Licensee the heater in the back of the building is not working properly, which is an immediate risk to the health and safety of residents in care.the state’s words, verbatim · CDSS document, Oct 27, 2023

Plan of correction: Licensee agrees to provide proof of service that heater in the back is working properly by POC due date.