Crestwood Hope Center

Type of visit: Case Management - Other

At approximately 12:25PM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a case management - other visit and met with Administrator Lovian Ekpenyong. The purpose of this visit was to follow up on an incident report (IR) submitted by the facility on 8/28/2026. IR states that a resident (R1) signed out for an individual outing on 8/27/2026 and did not return. Emergency services were activated and a missing person report was filed. During this visit, LPA was informed that R1 has not returned and facility considers them to be discontinued from the program due to the expiration of Medi-Cals 14 day bed hold. Review of resident care plan indicated that R1 was admitted 12/2025 and was allowed to leave unassisted if signed out on resident logbook. Review of Individual Outing Agreement dated 3/11/2026 indicated R1 agreed to solo outings if they signed out. Further review of Care Plan indicated R1 had a recent injury to their leg making ambulation unsteady, this injury and ambulation issue has since been resolved. Review of LIC602 – Physician Report dated 6/1/2026 indicated that R1 is not allowed to leave unassisted, but did not specify if this is a result of mental or physical limitations. Further review of LIC602 indicated R1 does not present confusion, wandering behaviors, and is able to care for their own Activities of Daily Living (ADLs). Interviews with staff indicated that R1 has been identified through care plans as being able to leave unassisted as long they sign-out. All sign-outs are logged in resident logbook. Interview with Administrator indicated that they have retrained staff on elopement procedures and which residents are able to leave unassisted. LPA reminded staff that residents who have been medically identified as being unable to leave unassisted must have staff accompaniment or have staff remain within line of sight. LPA advised facility to review LIC602s for residents in care and ensure they have been reviewed by a licensed professional. Continued LIC809C... Continued from LIC809... LPA also followed up on a change in management. Administrator Lance Woodson is no longer with the facility, Lovian Ekpenyong will take over as Administrator. Licensee shall submit the following documents by 10/13/2026 to Community Care Licensing (CCL): Copy of active and current Administrator Certificate Copy of Board of Directors Resolution Meeting Minutes Signed Administrator Resume LIC501 - Personnel Record LIC308 - Designation of Facility Responsibility No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Sep 29, 2026

Allegation investigated: Staff does not provide resident medications as prescribed.

At approximately 11:05AM, Licensing Program Analyst (LPA) Magdaleno arrived unannounced to deliver findings regarding the above allegation and met with Adminsitrator Lance Woodson. Staff does not provide resident medications as prescribed - Reporting Party (RP) alleges that facility does not dispense medications to resident (R1) as prescribed. During the course of this investigation, LPA made observations, conducted interviews, and reviewed records. LPA observed residents coming to the medication room to request their medications and staff dispensed the medications, if multiple residents came with medication requests, they were asked to form a line and wait their turn. Interviews with four (4) of four (4) staff indicated that there had been no reports from residents or other staff of residents being denied medication. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Further interviews with staff indicated that upon a PRN request from a resident, staff will ask the reason for the PRN, check the requested PRN against doctor’s order, and ensure the orders are followed correctly. Interviews with four (4) of six (6) residents indicated that they are dispensed medications upon request without incident, One (1) of six (6) residents interviewed indicated they do not have active medication orders. Review of R1s Medication Chart and Active Orders for March 2026 and May 2026 indicated that R1 is being dispensed medications as prescribed and PRN medications are being dispensed upon request. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 21-AS-20260401093416

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to conduct a Case Management - Other visit and met with Administrator Lance Woodson. This visit was to conduct to follow up and gather more information regarding an Incident Report (IR) submitted by the facility on 4/7/2026. The incident report detailed a resident (R1) who was observed with disorientation and heavy, labored breathing following a request for mouth wash. R1 was subsequently sent to the ER. Interview with staff and management indicated that mouth wash in the facility is non-toxic, and the reason for R1's ER visit was unrelated to the mouth wash. Facility will submit a follow up IR providing further information and diagnosis. LPA also followed up on a change in facility management, Administrator Vincent Waller is no longer with the facility. Lance Woodson will be taking over as Administrator, facility will submit the following documents to Community Care Licensing in order to update Administrator: Copy of active and current Administrator Certificate Copy of Board of Directors Resolution Meeting Minutes Signed Administrator Resume LIC500 - Personnel Report LIC501 - Personnel Record LIC308 - Designation of Facility Responsibility No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Apr 9, 2026

Type of visit: Required - 1 Year

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... 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.the state’s words, verbatim · CDSS document, Nov 10, 2025

The state marks this report as 5 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Allegation investigated: Staff do not allow resident to leave the facility

Licensing Program Analyst (LPA) Magdaleno arrived unannounced to continue a Complaint Investigation and deliver findings regarding the above allegations and met with Administrator Vincent Waller. During the course of this investigation LPA conducted interviews, made observations, and reviewed records. Staff do not allow resident to leave the facility – Reporting Party (RP) alleges that resident (R1) was not made aware that the facility is a locked facility and R1 was not allowed to leave the facility by staff. LPA conducted a tour of the facility and observed that it is not a locked facility but shares a reception area with a neighboring locked facility that is not under the purview of Community Care Licensing (CCL). The unlocked Crestwood Hope Center licensed by CCL allows residents to leave via the main reception area or through an unlocked gate in the back patio. Continued LIC9099C... Unsubstantiated Continued from LIC9099... Review of R1 LIC602-Physician Report indicated that R1 is able to leave unassisted. Interviews with staff indicated that residents are able to come and go as they please. Staff encourage residents to sign out but do not force it. Further interviews with staff and Administrator indicated that R1 was asked to stay within the facility without leaving throughout the process of registering R1 with the Police Department. Review of a message left by R1 to CCL indicated that R1 and facility have come to an agreement on entering and exiting. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Oct 30, 2025 · control 21-AS-20250919161326

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Magdaleno arrived at approximately 1:45 PM to conduct a Case Management-Other visit and was greeted by Administrator Vincent Waller. The purpose of this visit was to follow-up on a Death Report received by Community Care Licensing (CCL) regarding a resident who passed outside of the facility. Administrator stated they would submit Death Certificate and Coroner's Report as soon as they are made available. LPA requested documents and conducted interviews. No deficiencies cited. Exit interview conducted with Administrator, whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Oct 30, 2025

Type of visit: Required - 1 Year

On 12/27/2024, Licensing Program Analyst (LPA) A Canela conducted an unannounced Annual Required – 1 yr. Inspection for this Residential Care Facility for the Elderly. This facility is licensed for 24 non-ambulatory residents, none of which have a diagnosis of dementia and no approval hospice care. The facility currently provides care for 24 residents. Administrator, Vincent Waller (VW) was called and arrived a few minutes later. LPA toured the facility with Service Coordinator and made observations. The facility has made major changes to the facility and the facility layout is different from when they were originally licensed. Review of the files shows facility sent in a change of location application to Community Care Licensing in 2020. The facility was not changing their address location, but were changing the facility floor plan that they share with Crestwood Recovery & Rehab Center. LPA and Administrator will review application and sketch to ensure there is a current Fire clearance reflecting the new changes. Facility was at a comfortable temperature. Resident’s bedrooms, common areas were inspected. Fire Extinguisher was found charged and last inspected on 5/16/2024. Facility fire inspection and testing sprinkler and smoke alarm systems was last conducted on 3/2024. 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. There was a supply of hygiene products and paper products available for use. All resident bedrooms have lighting & appropriate furnishings. Continue report see LIC809-C LPA reviewed resident files and found them complete and organized. Residents had current medical assessments, all residents checked were ambulatory. Staff files are current, with proof of CPR/1st Aid. Vincent Waller, Administrator Certificate 7027164740 expires 1/18/2026. Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit: LIC500- Personnel Report LIC308- Designation of Responsibility LIC610E- Disaster Plan LIC9020- Resident Roster Evidence of Liability Insurance Copy of Administrators Certificate No citations issued during this visit.the state’s words, verbatim · CDSS document, Dec 27, 2024

Allegation investigated: Suspicious death

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 27, 2024 · control 21-AS-20240305160835

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Dec 28, 2023