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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803573
Report Date: 08/22/2023
Date Signed: 08/22/2023 04:20:52 PM

Document Has Been Signed on 08/22/2023 04:20 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:
08/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rose Salgado-Licensee/AdministratorTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analysts(LPAs) Alviso and Coppo arrived unannounced to conduct a Required -1 Year visit, at approximately 10:00am on 8/22/23, and met with Licensee Rose Salgado. There are currently six(6) clients in care; Three(3) clients are at day program.

Facility is fire cleared for six(6) ambulatory clients. Facility has an emergency disaster plan as required. Facility has an infection control plan as required.

LPAs toured the facility with the Licensee. LPAs observed that there was a sufficient supply of food. There was a sufficient supply of cleaning products, paper products, and personal protective equipment(PPE) for use as needed. All exits were cleared. The following deficiencies were cited:

LPAs' observed medication cabinet opened due to the lock being loosly put on it, not being set and locked; LPA could see medications and reached in and took medications out of the cabinet right through the loose lock device on the cabinet. LPAs observed numerous over the counter medications in a room occupied by a tenent of the Licensee. These medications were also available to all residents in care. This deficiency will be cited, 80075(k)(1) Health Related Service - Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication, see LIC809D.

LPAs observed that the facility fire extinguisher was not serviced and tagged as required, it expired 8/5/23, this deficiency will be cited, 80020(a) Fire Clearance -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, see LIC809D.

Continued on LIC809C...
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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 6
Document Has Been Signed on 08/22/2023 04:20 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/22/2023 at 03:11 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs {observation/record reviews, no staff had an LIC Health Screening and TB Test w/Results, the licensee did not comply with the section cited above in [4} out of [4] staff, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee to ensure that all staff have a health scrrening report and TB test w/ results on file. Licensee to submit the plan of correction on having staff obtain the health scrrening. On 8/31/23 submit copies of all staff health Screenings, including TB results. Plan Of Correction due 8/23/23.
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs {observation/record reviews, three(3) staff lacked current first aid, the licensee did not comply with the section cited above in [3} out of [4] staff, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee to ensure that all staff have current first aid certification, including CPR on file. must have First Aid, and one person on shift must also have CPR certification. Licensee to submit the plan of correction on having staff obtain First Aid, and CPR if neededg. On 8/28/23 submit copies of all staff first aid certificates, and CPR if obtained. Plan Of Correction due 8/23/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/22/2023 04:20 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/22/2023 at 03:11 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80076(a)(7)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observed two mayonnaise jars that were opened and stored in a kitchen cabinet; The jar(s) states to refrigerate after opening. Four cans of expired chicken- expired 12/2022. Rice in a pot on the counter from the night before, per staff. Raw meat in a large bowl with sauce on it marinating on the kitchen counter, it was also uncovered., the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee to ensure all food is stored appropriately per regulations. Review food policy and procedures of the facility, in line with regulations, and hold an in-service training with all staff. Submit proof of training, and pictures of food storage, facility policy and procedures by 8/31. Submit plan of correction by 8/23/23.
Type A
Section Cited
CCR
80020(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

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation the facility fire extinguisher was not serviced and tagged as required, it expired 8/5/23, the licensee did not comply with the section cited above in [1] out of [1) fire extinguisher, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee to ensure the fire extinguisher gets serviced and tagged as required. Submit proof of service, copy of receipt, and a picture of the tag. POC due 8/23/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/22/2023 04:20 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/22/2023 at 03:11 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs [(observation)] The facility had cob webs in many areas of the facility, large ones, some with dead and/or alive spiders. The LPAs observed a resident's bathroom toilet to be dirty and around the basin there was no caulking. Kitchen counters, stove, and range hood were all dirty and covered with sticky old oil film. LPAs observed dirty dishes and bowls in the cabinet. The slider door doesn't have a working lock., the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/01/2023
Plan of Correction
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Licensee to ensure the facility is kept clean, sanitary and in good repair for clients, staff and all other visitors to the home. Submit plan of correction in how the items stated above were cleaned, repaired/replaced, and also a plan of maintaining the facility in compliance with this regulation. POC due 9/1/23, include pictures.
Type B
Section Cited
CCR
80065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs (record reviews)], no staff had proof of training, the licensee did not comply with the section cited above in [4] out of [4] staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/08/2023
Plan of Correction
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Licensee to ensure all staff have training per regulations, and ensure a file is on-site and available for review. Submit plan of correction, and copies of staff training no later than 9/8/23. POC due 9/8/23.
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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/22/2023 04:20 PM - It Cannot Be Edited


Created By: Dina Alviso On 08/22/2023 at 03:46 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(k)(1)
Health-Related Services
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), LPAs observed medication cabinet opened due to the lock being loosly put on it, not being set and locked; LPA could see medications and reached in and took medications out of the cabinet right through the loose lock device on the cabinet. LPAs observed numerous over the counter medications in a room occupied by a tenent of the Licensee. These medications were also available to all residents in care.] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Licensee to ensure all medications are locked up and secured at all times. Hold an inservice with all staff and submit proof of training, and pictures of locked cabinet, and plan of ensuring all staff follow medication policies, submit by 8/31/23. Plan of correction due 8/23/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Carla Martinez
LICENSING EVALUATOR NAME:Dina Alviso
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: E.R.SALGADO,INC./SAINT LUCIA RESIDENTIAL CARE
FACILITY NUMBER: 286803573
VISIT DATE: 08/22/2023
NARRATIVE
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LPAs observed two mayonnaise jars that were opened and stored in a kitchen cabinet; The jar(s) states to refrigerate after opening. Four cans of expired chicken- expired 12/2022. Rice in a pot on the counter from the night before, per staff. Raw meat in a large bowl with sauce on it marinating on the kitchen counter, it was also uncovered. This deficiency will be cited, 80076(a)(7) Commercial foods shall be approved by appropriate federal, state and local authorities. All foods shall be selected, transported, stored, prepared and served so as to be free from contamination and spoilage and shall be fit for human consumption. Food in damaged containers shall not be accepted, used or retained, see LIC809D.

LPAs observed during record reviews, Three(3) staff lack current first aid training. This deficiency will be cited, 80075(f) Health Related Services- Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross, see LIC809D.

Per review of records, LPAs observed there was no proof of staff training. This deficiency will be cited, 80065(f) Personnel Requirements-All personnel shall be given on-the-job training or shall have related experience which provides knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance, see LIC809D.

Updated copies of the following documents were requested for facility file and are to be submitted by 9/22/23.


LIC 500 Personnel Report
LIC 610 Emergency Disaster Plan
LIC 308 Designation of Responsibility
Control of Property
Register of Clients
Infection Control Plan-any updates

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. This report was read and discussed with Licensee/Administrator Rose Salgado.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Dina Alviso
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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