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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803228
Report Date: 12/28/2023
Date Signed: 12/28/2023 12:02:43 PM


Document Has Been Signed on 12/28/2023 12:02 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
SANTA ROSA RO, 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: 21DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Vincent WallerTIME COMPLETED:
12:10 PM
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LPA Hiratsuka conducted this unannounced annual visit. LPA toured the facility with Administrator Vincent Waller.

This facility is licensed for 24 non-ambulatory residents. The main entrance opens to a lobby that is shared with another program that is not licensed by Community Care Licensing. There are twelve shared resident rooms that have private half-bathrooms. There is one common shower room that has three showers. There is an interior outdoor courtyard and an outside partial perimeter courtyard. There are several offices, storage, one laundry room, a medication room, and several common areas for the residents. The kitchen is shared with the other program and is on the other side but the food is transported in appropriate containers to the dining area for the residents.

Several rooms were inspected. The common areas were toured. Resident records and staff records were reviewed.

Multiple topics were discussed

The following was received during this visit:
-LIC 308 Designation of Administrative Responsibility
-LIC 500 Facility personnel or staff schedule

The following shall be updated and submitted to Community Care Licensing Division by January 16, 2024:
-currently liability insurance
-current lease agreement

No deficiencies cited.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Kerry HiratsukaTELEPHONE: (916) 591-0210
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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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