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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803228
Report Date: 10/07/2022
Date Signed: 10/07/2022 02:17:58 PM


Document Has Been Signed on 10/07/2022 02:17 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:DONNABELL GALACIAFACILITY TYPE:
740
ADDRESS:115 ODDSTAD DRIVETELEPHONE:
(707) 552-0215
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:24CENSUS: 21DATE:
10/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Vincent Waller, AdministratorTIME COMPLETED:
02:30 PM
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On 10/7/2022, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Administrator, Vincent Waller (VW). The facility currently provides care for 21 residents none of which have a diagnosis of dementia, none of which are on hospice and all of which were present at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator; 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 5/9/2022 at the time of the visit. Facility fire inspection testing sprinkler and smoke alarm systems was last conducted on 1/8/2022. There was a sufficient supply of both perishable and nonperishable foods for residents in care. Food storage was observed and found to be properly stored with items labeled as per Title 22 Regulations. LPA conducted a sample 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 with the facility staff conducting routine cleaning during shift changes or and every two hours. There was a supply of hygiene products and paper products available for use. Resident restrooms are all equipped with soap and paper towel dispensers which are replenished on a regular basis . All resident bedrooms have lighting & appropriate furnishings with sliding door exits found to be free of any obstructions.

Continued onto LIC9099-C
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2022
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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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: 10/07/2022
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Infection Control:
Facility has submitted an infection control plan to CCLD for review. All staff have received COVID full vaccination and subsequent boosters. Surveillance testing is being conducted for all staff and residents every 2-3 weeks. Posters for COVID prevention have been placed throughout the facility, with a station at main entrance with a sign in binder, hand sanitizer and other items designated for visitors and staff. Staff and residents are screened for temperature and symptoms twice per day or due to change of condition.

No deficiencies cited during today's visit. Appeal rights given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022
LIC809 (FAS) - (06/04)
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