Crestwood Wellness and Recovery Center

In the surveyor’s words

From the most serious findings on record at Crestwood Wellness and Recovery Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jun 4, 2025

  Based on observation, interview, and record review the facility failed to store food in accordance with professional standards when they failed to label and date food product bags after opening the bags for use. The open, unlabeled, and undated product bags contained frozen soy chicken patties, frozen fried eggs, and frozen soy beef patties. This failure had the potential for the food products to be used for meals in an untimely manner leading to bacterial or fungal growth resulting in food borne illnesses amongst residents. Findings: During a review of the facility's policy and procedure titled, Labeling and Dating of Foods, dated 2020, indicated, Newly opened food items will need to be closed and labeled with an open date and used by the date that follows guidelines . […]

• No harm, potential for more than minimal, patternF600Jun 20, 2024

  Based on interview and record review, the facility failed to ensure that two of 20 sampled residents (Residents 3 and 82) were protected from physical abuse when: 1. On 6/12/24, Resident 84 struck Resident 82 in the face. 2. On 5/22/24, Resident 84 placed their hands around Resident 3's throat. This failure resulted in bleeding injuries to Resident 82, and had the potential to threaten the physical, emotional and psychological health and well-being of both residents. Findings: A facility policy, titled, Client (resident) Abuse Prevention, updated 4/5/22, was reviewed. The policy indicated clients should not have been subjected to verbal or physical abuse of any kind and clients should not have disciplined other clients. […]

• No harm, potential for more than minimal, patternF812Jun 20, 2024

  Based on observation, interview, and record review the facility failed to store food in accordance with professional standards when they failed to label and date food containers/ product bags of frozen breaded fish, frozen fried eggs, frozen hashbrowns, frozen frenchtoast, pepperoni, and peeled garlic cloves with open dates after the packages were open and the products being used for meals. This failure had the potential to allow food products to sit an inappropriate amount of time after the packaging was open with no dating label adehered leading to bacterial or fungal growth causing food borne illnesses amongst residents if the product was served for meals and not used by an appropriate date following guidelines. […]

• No harm, potential for more than minimal, isolatedF600Jan 9, 2026

  Based on interviews and record reviews the facility failed to protect the rights of one out of four sampled residents (Resident 1) to be free from physical abuse by Resident 2 when Resident 2 hit Resident 1 in the face. This resulted in Resident 1 sustaining bruising to the right side of the face that lasted for 15 days. Findings: A review of the facility's policy and procedure (P&P) titled, Crisis Intervention Program, updated 6/1/25, indicated, facility staff would recognize early warning signs of crisis (notice changes in behavior, mood, or thinking). The P&P indicated staff would provide early intervention (action and support provided to the resident from staff) when a resident exhibited an increase in behaviors (acting out). […]

• No harm, potential for more than minimal, isolatedF609Jan 9, 2026

  Based on observations, interviews, and record reviews, the facility failed to report an allegation of sexual abuse to the California Department of Public Health (CDPH, state agency dedicated to protecting and improving the health of Californians), the police department, and to the local Ombudsman [a person who worked to maintain resident rights] for one out of two sampled residents (Resident 3) when Resident 3 made statements about being sexually abused. This had the potential to negatively impact health status and psychosocial well-being. Findings: A review of the facility's policy and procedure (P&P) titled, Client Abuse Prevention, updated 10/14/24, indicated, Staff will immediately and directly report to the Administrator any suspicions of client abuse, either witnessed or suspected. […]