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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803573
Report Date: 09/03/2024
Date Signed: 09/03/2024 11:08:25 AM

Document Has Been Signed on 09/03/2024 11:08 AM - 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: DATE:
09/03/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Rose Salgado-Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:15 AM
NARRATIVE
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An informal meeting was conducted today in the Santa Rosa Regional Office. Present in the meeting were Licensing Program Manager, Bethany Moellers, Licensing Program Analysts, Julie Florio and Christopher Arnhold, and Licensee/Administrator, Rose Salgado.

The purpose of the informal office meeting was to discuss areas of non-compliance and ongoing observed concerns in the of the operation of E.R. Salgado, Inc./Saint Lucia Residential Care # 286803573. The Licensee was informed that this informal meeting is a part of the Administrative Action process and that further and/or repeat citations may result in a formal Non-Compliance Plan. The legal administrative action process was explained to attendees which is based on deficiencies found during annual visit conducted on August 15, 2024.

Items addressed in today's meeting include but are not limited to patterns and trends in the areas below:

- Fire Clearance
- General Food Requirements – including good quality food.
- Medication Management
- Personnel Records – must be complete with required documentation.
- Client Records – must be complete with required documentation.
- Administrator Qualifications and Duties
- First Aid Requirements – Administrator to ensure that all staff have proof of current First Aid given by American Red Cross.
- Buildings and grounds
- Live-in Staff/Volunteers

Continued on LIC809C...
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE: DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/03/2024
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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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: E.R.SALGADO,INC./SAINT LUCIA RESIDENTIAL CARE
FACILITY NUMBER: 286803573
VISIT DATE: 09/03/2024
NARRATIVE
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- Licensee submitted updated LIC500 personnel summary and included all staff specific days/hours on shift, including administrator.

LPA Advised the following documents be present in facility records:
- Proof of First Aid Certification for each staff member noted in annual inspection report.
- LIC501: Job application for each staff member noted in annual inspection report.
- LIC503: Health Screening for each staff member noted in annual inspection report.
- Proof of Negative TB results for each staff member noted in annual inspection report.
- LIC602: Physician’s Report for the client noted in annual inspection report.
- Proof of Negative TB results for the client noted in annual inspection report.
- LIC613: Personal Rights for the client noted in annual inspection report.
- Proof of Negative TB results for Tenant.
- Licensing staff discussed Technical Support Program (TSP) that offers advice, guidance, a review of facility operation, discusses best practice, and required regulation/HSC compliance. Licensee agreed to utilize the TSP assistance benefit.
- Failure to submit any of the above requested documentation may result in the Department seeking further action.

Licensee was informed that a citation and an immediate civil penalty are being issued today for the fire clearance violation observed during the 8/15/2024 annual inspection due to one backyard gate observed obstructed with a board, stone, and containers, and the other backyard gate locked with padlock, (see pictures). 80020 Fire Clearance (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal. Additionally, a citation for expired food observed during annual inspection was cited during today's office meeting.

The following deficiencies were observed and cited (see LIC 809-D) from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Administrator and appeal of rights provided. Signature on form confirms receipt.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/03/2024 11:08 AM - It Cannot Be Edited


Created By: Julie Florio On 09/03/2024 at 10:32 AM
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: 09/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/03/2024
Section Cited
CCR
80020(a)

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All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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Licensee submitted picture proof that the padlock and obstructions have been removed from the backyard gates to CCLD at today's office visit 9/3/2024. POC cleared.
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring that the backyard exit gates were unlocked and free from obstruction, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
09/13/2024
Section Cited
CCR80076(a)(7)

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80076 Food Services: (a)... ( 7) Commercial foods shall be… stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption….
This requirement is not met as evidenced by:
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Licensee agrees to submit a self-certification that all food in the facility has been inspected and is within the label expiration date to CCL by POC due date 9/13/2024.
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Based on observation, the licensee did not comply with the section cited above in ensuring food is in good quality and not expired which poses a potential 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: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/03/2024


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