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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803228
Report Date: 12/27/2024
Date Signed: 12/27/2024 04:08:24 PM

Document Has Been Signed on 12/27/2024 04:08 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:CRESTWOOD HOPE CENTERFACILITY NUMBER:
486803228
ADMINISTRATOR/
DIRECTOR:		WALLER, VINCENTFACILITY TYPE:
740
ADDRESS:115 ODDSTAD DRIVETELEPHONE:
(707) 552-0215
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 24TOTAL ENROLLED CHILDREN: 0CENSUS: 24DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:09 PM
MET WITH:Vincent Waller, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
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On 12/27/2024, Licensing Program Analyst (LPA) A Canela conducted an unannounced Annual Required – 1 yr. Inspection for this Residential Care Facility for the Elderly. This facility is licensed for 24 non-ambulatory residents, none of which have a diagnosis of dementia and no approval hospice care. The facility currently provides care for 24 residents. Administrator, Vincent Waller (VW) was called and arrived a few minutes later.

LPA toured the facility with Service Coordinator and made observations. The facility has made major changes to the facility and the facility layout is different from when they were originally licensed. Review of the files shows facility sent in a change of location application to Community Care Licensing in 2020. The facility was not changing their address location, but were changing the facility floor plan that they share with Crestwood Recovery & Rehab Center. LPA and Administrator will review application and sketch to ensure there is a current Fire clearance reflecting the new changes.

Facility was at a comfortable temperature. Resident’s bedrooms, common areas were inspected. Fire Extinguisher was found charged and last inspected on 5/16/2024. Facility fire inspection and testing sprinkler and smoke alarm systems was last conducted on 3/2024. Review of staff CPR & 1st Aid certification and found records to be sufficient.

Toxins and cleaning supplies are stored and secured in both the facility laundry and maintenance rooms. There was a supply of hygiene products and paper products available for use. All resident bedrooms have lighting & appropriate furnishings.

Continue report see LIC809-C
Kimberley MotaTELEPHONE: (707) 588-5051
Araceli CanelaTELEPHONE: (707) 588-5041
DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CRESTWOOD HOPE CENTER
FACILITY NUMBER: 486803228
VISIT DATE: 12/27/2024
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LPA reviewed resident files and found them complete and organized. Residents had current medical assessments, all residents checked were ambulatory. Staff files are current, with proof of CPR/1st Aid. Vincent Waller, Administrator Certificate 7027164740 expires 1/18/2026.


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
LIC308- Designation of Responsibility
LIC610E- Disaster Plan
LIC9020- Resident Roster
Evidence of Liability Insurance
Copy of Administrators Certificate

No citations issued during this visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
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