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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803228
Report Date: 08/27/2024
Date Signed: 08/27/2024 10:11:45 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240305160835
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: 23DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lance Woodson/AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Suspicious death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This Department has investigated the allegation by interviewing witnesses, reviewing documents, including medical records and making site visit to facility. The following determinations are made: R1 died on 2/21/2024 with cause of death listed as inflammatory colitis and severe end stage constipation. R1 had history of constipation due to prescribed medications. R1 was independent and did not require staff assistance with activities and hygiene. Facility records indicate normal bowel movements for R1 on the day preceding hospitalization. R1 did not complain of pain or of symptoms that would suggest a bowel problem to staff prior to 02/19/2024 when R1 did complain of stomach pain which resulted in R1 being sent out by staff for medical care. Although the allegation may be true, based on interviews and documents, there is not a preponderance of evidence to prove or, disprove, the allegation. Therefore, the allegation is UNSUBSTANTIATED.
Report left.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/05/2024 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20240305160835

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: 23DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Lance Woodson/AdministratorTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not seek medical care for resident in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst Leibert arrives unannounced for the purpose of delivering findings on this complaint. This Department has investigated the allegation by interviewing witnesses, reviewing documents, including medical records and making site visit to facility. The following determinations are made: On 2/19/2024R1 complained of stomach pain to staff and was evaluated by facility nurse who determined that R1 should be sent out for medical care. Facility records and staff statements indicate that R1 did not complain of pain or exhibit systems prior to 2/19/2024. R1 is independent and is able to communicate R1’s needs to facility staff. Based upon the statements and records, R1 showed no signs of distress or change of condition prior to the morning of 2/19/2024. Therefore, the allegation that staff did not seek medical care for R1 in a timely manner is UNFOUNDED, meaning that it is false and/or, without a reasonable basis. The Allegation is DISMISSSED.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2