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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803573
Report Date: 08/09/2021
Date Signed: 08/26/2021 02:01:13 PM

Document Has Been Signed on 08/26/2021 02:01 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
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:E.R.SALGADO,INC./SAINT LUCIA RESIDENTIAL CAREFACILITY NUMBER:
286803573
ADMINISTRATOR:ROSE SALGADOFACILITY TYPE:
735
ADDRESS:134 LANDANA STREETTELEPHONE:
7073154838
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 6CENSUS: 6DATE:
08/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Rose SalgadoTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA), Angela Elliott arrived unannounced to conduct an Annual inspection at approximately 9:20 AM, and met with administrator Rose Salgado. The inspection is focused on the Infection Control procedures and practices of this facility.

Posting on the door indicated "No Visitors." LPA explained to Licensee residents have a right to have visitors. Upon entry LPA was greeted by staff without masks. LPA was not screened before entering. LPA provided guidance to be diligent about routine symptoms screening and documentation. LPA was shown client and staff temperature records last dated 8/9/2021. There is no screening questionnaire as part of the screening
process. LPA conducted walk through of the facility with Licensee and observed COVID-19 postings. Hand washing sign were posted in the restrooms. Mitigation plan has been submitted and approved by Community Care Licensing (CCL).

Facility was a comfortable temperature and exits were free from obstructions. While touring facility LPA and Licensee heard a smoke alarm that was beeping. 2 out of 6 smoke detectors were not functioning due to not functioning. LPA requested to see Latest Fire Inspection Report for the facility. Licensee could no produce
report. Fire Extinguisher was last inspected 6/13/2019. Hand sanitizer is kept in common areas. Licensee
indicated if visitors were to come in they would visit in the second living room or client bedroom. Visits are
primarily outdoor. Licensee indicated visitors don't want to come into the facility. Licensee reported they have
two Independent Living residents that access the community and one client that goes to a day program once a
week starting tomorrow. LPA and Licensee discussed the need to have screening procedures when clients return from the community. Licensee and LPA discussed all residents at the facility fall under Title 22 regulations and Provider Information Notice (PIN) guidance from Community Care Licensing (CCL). Licensee reported
staff have completed Personal Protective Equipment (PPE) and infection control training but did not have training documentation. Licensee indicated staff have not been N-95 fit tested. Licensee indicated she would go to her house and get the training records. When Licensee returned there were no training records
available. Meals are occurring at the dining table and the facility layout provides room for social distancing.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: E.R.SALGADO,INC./SAINT LUCIA RESIDENTIAL CARE
FACILITY NUMBER: 286803573
VISIT DATE: 08/09/2021
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Licensee indicated the facility is disinfected twice daily and is cleaned after each meal. Due to current facility
census, residents could isolate in their rooms if they became ill. LPA confirmed licensee had necessary
PPE equipment and supplies to support a client in isolation. Licensee indicated they would need to move clients around to create an isolation room.

Clients emergency contact information has been updated and Licensee confirmed staff are familiar with 911 procedures and protocols. Toxins are secured and inaccessible in the garage. A 30 day supply of medications
are stored in a locked cabinet off of the kitchen. The facility has a sufficient supply of Personal Protective
Equipment (PPE). Hygiene supplies and linens are stored in a cabinet in the garage. All exit alarms on doors were working properly.

Licensee stated that there is currently no ongoing survelliance testing of staff. There is no documentation of staff regular surveillance testing. Licensee indicated staff were tested a few months ago. LPA provided
Licensee a copy of PIN 21-31 "Updated Facility Staff Testing and Masking Guidance for Coronavirus Disease
2019".

LPA had discussion with Licensee that staff wearing masks is mandatory.

Licensee and LPA discussed their Emergency Disaster Plan which is outdated. Licensee showed LPA a copy of Emergency Disaster Plan from 10/1/2019. LPA requested a copy of updated Emergency Disaster Plan by 8:00 AM 8/11/2021.

LPA issued Technical Assistance for staff not wearing masks, staff training, facility screening process for visitors and residents, N-95 Fit Testing, staff surveillance testing, personnel records, and buildings and
grounds. LPA requested self-certification that smoke detectors are working by 8/9/2021.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Angela Elliott
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
LIC809 (FAS) - (06/04)
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