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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803573
Report Date: 08/15/2024
Date Signed: 08/15/2024 09:05:21 PM

Document Has Been Signed on 08/15/2024 09:05 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:E.R.SALGADO,INC./SAINT LUCIA RESIDENTIAL CAREFACILITY NUMBER:
286803573
ADMINISTRATOR/
DIRECTOR:		ROSE SALGADOFACILITY TYPE:
735
ADDRESS:134 LANDANA STREETTELEPHONE:
(707) 315-4838
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 6CENSUS: 5DATE:
08/15/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Eldimira Atilano, Caregiver/Responsible PartyTIME VISIT/
INSPECTION COMPLETED:
12:50 PM
NARRATIVE
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At approximately 11:40 AM, Licensing Program Analyst (LPA), Julie Florio arrived unannounced to conduct a Case Management - Incident visit and was greeted by Eldimira Atilano, Caregiver/Responsible Party (RP). Licensee was telephoned and reported they were unable to be present for today's visit. Licensee did arrive at the facility at approximately 1:45 PM.

On 5/24/2024 LPA conducted 10-day follow up visit at facility to open a complaint. At which time, Licensee was unable to provide LPA with requested client (C1) records or medical follow up documents regarding the outcome of a head injury C1 sustained. Licensee submitted C1's records via email by COB 5/24/2024 and noted that they would submit proof of C1's medical visit by 5/28/2024. CCLD has not received the requested documents. LPA attempted to contact Licensee via email on 7/31/2024 and via telephone message on 8/13/2024 to provide proof of the visit and the medical outcome of both the visit and the head scan C1 reportedly had on 5/28/2024. LPA did not receive a response from Licensee. LPA is citing 80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client. (See LIC809D).


Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, or repeat violations within a 12-month period, may result in a civil penalty assessment. Appeal rights provided to Licensee.

Exit interview conducted with Licensee, whose signature confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2024
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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Document Has Been Signed on 08/15/2024 09:05 PM - It Cannot Be Edited


Created By: Julie Florio On 08/15/2024 at 12:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: E.R.SALGADO,INC./SAINT LUCIA RESIDENTIAL CARE
FACILITY NUMBER: 286803573

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2024
Section Cited
CCR
80070(a)

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80070 Client Records (a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.

This requirement is not met as evidenced by:
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Licensee to submit documentation of C1's office visit on 5/20/24 and the results of C1’s head scan to CCLD by POC due date 8/22/2024.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring that a separate, complete, and current record is maintained in the facility for each client which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Julie Florio
LICENSING EVALUATOR SIGNATURE:
DATE: 08/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/15/2024


LIC809 (FAS) - (06/04)
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