<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803573
Report Date: 08/04/2022
Date Signed: 08/04/2022 03:23:02 PM

Document Has Been Signed on 08/04/2022 03:23 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:E.R.SALGADO,INC./SAINT LUCIA RESIDENTIAL CAREFACILITY NUMBER:
286803573
ADMINISTRATOR:ROSE SALGADOFACILITY TYPE:
735
ADDRESS:134 LANDANA STREETTELEPHONE:
(707) 315-4838
CITY:AMERICAN CANYONSTATE: CAZIP CODE:
94503
CAPACITY: 6CENSUS: 6DATE:
08/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator, Rose SalgadoTIME COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Erik Gonzalez Campos arrived unannounced on 08/04/2022 to conduct a Required 1-Year Inspection, LPA was initially greeted by staff. Administrator, Rose Salgado arrived later. Inspection is focused on the infection control practices and procedures of this facility.

LPA toured facility with administrator. Facility has four bedrooms all of which have two bedrooms. LPA also observed a small bed in the living room. Per administrator the three shared bedrooms at the rear of the house are the rooms occupied by the clients. There are currently six clients in care. The fourth bedroom located off of the family room as designated by the facility sketch is currently used by staff. The bed located in the living room is only used for naps during the day. LPA observed one disinfectant cleaner on shelf directly in front of the entrance. LPA also observed laundry detergent in client bedroom. Per client they bought it themselves. Administrator stated clients are able to do laundry themselves. LPA reviewed 1 client file which indicated client is able to leave the facility unassisted and is independent with activities of daily living. LPA observed unattended medications above the medication drawer. Staff indicated that they were preparing medications to give to clients. LPA and administrator discussed the regulation regarding medication storage. Facility was a comfortable temperature and exits were free from obstructions. Building and grounds were clean and in good repair.

LPA is requesting the following documents be submitted to Community Care Licensing within 30 days of the inspection: LIC 602s for all clients, LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 9020 Client Roster, LIC 610 Emergency Disaster Plan, CPR Certificate, Infection Control Plan

No deficiencies cited during today's inspection. Exit interview conducted with administrator and a copy of this report printed for the facility.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Erik Gonzalez Campos
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2022
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 5