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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803228
Report Date: 11/10/2025
Date Signed: 11/10/2025 12:53:15 PM

Document Has Been Signed on 11/10/2025 12:53 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/
DIRECTOR:		WALLER, VINCENTFACILITY TYPE:
740
ADDRESS:115 ODDSTAD DRIVETELEPHONE:
(707) 552-0215
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 24CENSUS: 19DATE:
11/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Campus Administrator Lance Woodson
Staff Coordinator Dioselinne Sanchez
Service Coordinator Danvie Cardano		TIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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At approximately 9:30 AM, Licensing Program Analyst (LPA) Elias Magdaleno arrived unannounced to conduct a required 1-year annual inspection and was greeted by Staff Coordinator Dioselinne Sanchez Alvarez. Program Administrator Vincent Waller was called and informed of the visit but was unable to attend, Campus Administrator Lance Woodson arrived shortly after. Facility is a Residential Care Facility for the Elderly (RCFE) with nineteen (19) residents in care and is approved for all non-ambulatory residents.

At approximately 10:00 AM, LPA initiated a tour of the facility with Staff Coordinator and Campus Administrator and observed the following: Facility consists of one (1) story, was a comfortable temperature, and passageways were free from obstructions. Facility shares a campus and reception area with a locked facility not licensed by Community Care Licensing. Fire extinguishers were last inspected 4/25. Smoke and Carbon Monoxide detectors are hardwired and serviced by a third party vendor, last serviced 9/25. Water temperature measured between 105.6- and 116 degrees F, which is within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of clean linens, hygiene, incontinence care, and paper products available for residents. Spot check of residents' bedrooms were inspected and observed to have all the appropriate furnishings as outlined in Title 22 regulations and private bathrooms contained soap/paper towel dispensers. Closets containing cleaning supplies and other items that could pose a risk were locked.

Facility kitchen provides meals for both the locked and unlocked facility, LPA observed food is stored and transported in a safe manner. There is a shaded outdoor space for activities and facility events. Facility has an internet access device and internet available to residents in care, and the phone was tested and operational during today's inspection. Facility also provides a private phone room with a land line phone for resident usage.

Continued LIC809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: CRESTWOOD HOPE CENTER
FACILITY NUMBER: 486803228
VISIT DATE: 11/10/2025
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Continued from LIC809...

LPA observed an activity calendar, multiple activity rooms including a library and movie room, and observed staff conducting activities with residents. Facility conducts quarterly disaster drills, and the most recent drill was conducted 10/25. LPA observed a supply of PPE, emergency supplies, a first aid kit, and flashlights.


At approximately 10:30 AM LPA conducted a review of five (5) resident records.

At approximately 11:05 AM LPA conducted review of five (5) staff records. All required documentation present.

At approximately 11:50 AM LPA and Service Coordinator Danvie Cardano conducted a spot check of medication and medication records. Medication is centrally stored and locked.

Vincent Waller Administrator Certificate 7027164740 expires 1/18/2026.



Updated copies of the following documents shall be submitted to CCL within 30 days of this visit:

Liability Insurance
Lease Agreement
LIC400 - Affidavit Regarding Client Cash Resources
LIC610E - Emergency Disaster Plan

No deficiencies cited. Exit interview conducted with Service Coordinator, whose signature on form confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Elias Magdaleno
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2025
LIC809 (FAS) - (06/04)
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