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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803228
Report Date: 05/05/2022
Date Signed: 05/05/2022 11:17:40 AM


Document Has Been Signed on 05/05/2022 11:17 AM - 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:DONNABELL GALACIAFACILITY TYPE:
740
ADDRESS:115 ODDSTAD DRIVETELEPHONE:
(707) 552-0215
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:24CENSUS: 22DATE:
05/05/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Donnabell Galacia, Administrator TIME COMPLETED:
11:30 AM
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On 5/5/2022 LPA Tobola conducted an unannounced case management visit and was greeted by Administrator, Donnabell Galacia. The purpose of the visit is to follow up on Incident Reports regarding missed medications for resident (R1) that was observed during medication audit by facility LVN for the months of February and March 2022.

LPA conducted a spot medication count with medtech staff (S1). Facility tracks and logs all administered medications in an electronic Medication Administration Record system. LPA found medication to be in order from observed spot medication count.

Administrator stated that a full medication audit is conducted at the end of each month. Medtech staff are also responsible for medication debriefings between every shift change to ensure compliance. Administrator has implemented 2 out of 3 medication training for staff including medication administration and medication error reporting. Administrator has also developed system in which staff are able to request for an outside licensed professional to administer resident injections if facility LVN is unable to conduct the task.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2022
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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