486803228-10-15-2021-21-AS-KMOA-C82RDS-20211022125624

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803228
Report Date: 10/15/2021
Date Signed: 10/15/2021 03:42:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/02/2021 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20210302085556

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
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Donabell Galacia, Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility staff did not seek medical attention in a timely manner
Facility staff did not address a change in resident's condition

INVESTIGATION FINDINGS:

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On 10/15/2021 LPA Tobola conducted a complaint investigation to deliver findings and met with Administrator Donabell Galacia (DG). LPA toured the facility, reveiewd facility records, resident records and conducted interviews with staff and outside parties.

Complaint alleges facility staff did not seek medical attention in a timely manner for resident (R1). Based on a file review of facility incident reports, R1 chart notes and interviews with staff and resident R1's conservator, LPA found that paramedics and Vallejo Police Department were contacted from an outside party other than R1's Conservator, requesting for R1 to be transferred to a hospital for medial assessment. LPA found that R1 refused the services on multiple occassions and was not deemed by emergency medical personnel necessary for R1 to receive medical attention.

Continued onto LIC909-C

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210302085556

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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Complaint alleges facility staff did not address a change in resident's condition. Based on interviews with staff, resident R1's conservator and review of facility records LPA found that R1 is legally conserved by San Francisco County Deputy LPS Conservator (DC). During an interview DC stated that the facility was in good and contact regarding R1's changes of conditions and provided timely incident reports on occurrence. In addition, facility keeps resident chart notes for R1 recording any changes of condition or notable incidents.

Allegations staff did not seek medical attention in a timely manner and facility staff did not seek change in resident's condition are found to be 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 allegations are UNSUBSTANTIATED. Appeal Rights Given.

LPA provided electronic copy of report. 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

LIC9099 (FAS) - (06/04)

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