<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803228
Report Date: 05/11/2023
Date Signed: 05/11/2023 03:35:29 PM


Document Has Been Signed on 05/11/2023 03:35 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:WALLER, VINCENTFACILITY TYPE:
740
ADDRESS:115 ODDSTAD DRIVETELEPHONE:
(707) 552-0215
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY:24CENSUS: 22DATE:
05/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Danvie Cardano, Service CoordinatorTIME 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
On 5/11/2023 Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management to follow up on several incident reports and SOC341 Reports of Suspected Abuse submitted by the facility. LPA was greeted by Lead Staff, Ollive NeSmith and continued with discussing the facility's actions to the incidents. Service Coordinator, Danvie Cardano arrived later in the visit. The report indicated resident (R1) responsible for altercations between four other residents resulting in residents (R2, R3, R4 & R5) to have been physically assaulted by R1.

The facility had initiated emergency services and transferred R1 to the Napa Crisis Center the day of the altercations on 4/4/2023. LPA was informed that R1 had requested to be discharged from the facility and was placed at a more appropriate level of care. LPA found that R1 had several medication refusals noted in progress notes prior to the incidents and had caused a change of behaviors.

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: 05/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1