486803228-10-15-2021-21-AS-DTOA-C7TUH3-20211015153515

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803228
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:36:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	CRESTWOOD HOPE CENTER		FACILITY NUMBER:	486803228
ADMINISTRATOR:	SHALON DEAN		FACILITY TYPE:	740
ADDRESS:	115 ODDSTAD DRIVE		TELEPHONE:	(707) 552-0215
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	24	CENSUS: 21	DATE:	10/15/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:14 AM
MET WITH:	Donnabell Galacia, Administrator		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Donnabell Galacia (DG). The facility currently provides care for 21 residents none of which have a diagnosis of dementia and none of which are on hospice. LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with (DG); Facility was at a comfortable temperature. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last inspected on 10/15/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. All staff have current CPR and 1st Aid training on file. Smoke and carbon monoxide detectors were tested and found to be in working order. Toxins are stored in a locked cabinet in the facility laundry and maintenance room. There was a supply of hygiene products and paper products available for use. All resident bedrooms have lighting & appropriate furnishings. Water temperature was measured at faucets accessible to residents and was measured between 114.4 and 125.0 degrees F, which is not within regulation between 105 and 120 degrees F. However, facility shares a central water heater with a second sectioned Rehabilitation Recovery Center and building kitchen. The water temperatures are adjusted depending on faucet proximity to central water heater. Maintenance Director immediately lowered water temperature. LPA reviewed Maintenance Director's water temperature log and was found to be completed daily. LPA explained regulation requirements and Maintenance Director agrees to submit a 10-day water temperature log to CCL by 10/28/2021 to ensure regulation requirement is met. Continued onto LIC9099-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: CRESTWOOD HOPE CENTER	FACILITY NUMBER: 486803228
	VISIT DATE: 10/15/2021

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan which has been reviewed. Majority of residents and all staff are vaccinated with no symptoms. Surveillance testing is being conducted at 50 percent twice per month for all staff. Posters have been placed at the front door, and facility has a station at main entrance with a sign in sheet, hand sanitizer and other items designated for visitors and staff. Staff and residents are screened for temperature and symptoms twice per day.

No deficiencies cited during today's visit. Appeal rights given.

LPA provided an electronic copy of the report to Administrator. Signatures on file.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2021

LIC809 (FAS) - (06/04)

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