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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 286803573
Report Date: 08/15/2024
Date Signed: 09/03/2024 11:11:36 AM

Document Has Been Signed on 09/03/2024 11:11 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: 7DATE:
08/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Rose Salgado, Licensee &
Eldimira Atilano, Caregiver/Responsible Party		TIME VISIT/
INSPECTION COMPLETED:
09:15 PM
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***AMENDED

On August 15, 2024, Licensing Program Analyst (LPA) Julie Florio noted six (6) citations and sixteen (16) technical violations in the annual inspection report when in fact nine (9) citations and eighteen (18) technical violations (TV) were issued during that visit. Upon further record review and conversations with Licensing Program Manager (LPM), LPA determined that a TV for California Code of Regulation (CCR) 80020(a) related to the facility’s fire clearance is being upgraded to a Type A citation with an immediate civil penalty, (see LIC809 Office Meeting report and corresponding LIC809D and LIC421IM). Additionally, a TV issued for CCR 80076(a)(7) regarding expired and improperly stored food is being upgraded to Type B citation, (See LIC809 Office Meeting report and corresponding LIC809D). Also, on 8/15/2024, LPA stated there were seven (7) clients living in the facility. Upon further record review and conversations with Licensing Program Manager (LPM), LPA determined that facility has five (5) clients, Tenant 1 (T1) renting a room, not an additional client. Therefore, facility is within compliance with their fire clearance capacity limit. LPA did not include references to picture evidence or specify which staff and clients were missing documents on 5/15/2024 -- both have been corrected below. LPA has amended the annual inspection report (LIC809 and LIC809Cs) and delivered the amended report to Licensee during today’s scheduled office meeting in the CCL regional office.

At approximately 12:50 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and was greeted by Staff 1 (S1), facility caregiver/responsible party. Licensee was contacted via telephone and arrived at approximately 1:45pm. Facility is an Adult Residential Facility with six (6) clients, one (1) Tenant, and one (1) staff currently living there. Facility is licensed for six (6) ambulatory clients. LPA was informed that five (5) clients left for Day Program; Client 1 (C1) and Tenant 1 (T1) were present during today’s visit.

Continued on LIC809-C...
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)
Page: 1 of 25
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: 08/15/2024
NARRATIVE
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***AMENDED
Continued from LIC809...
At approximately 1:00 PM, LPA initiated a tour of the facility with S1 and observed the following: Facility is a one-story home, was a comfortable temperature, and passageways were free from obstructions. LPA observed a white shelf with a lace curtain strung from it, extending to the opposite wall, making a separate space with a bed and dresser observed on the other side. S1 informed LPA the space is their sleeping/living area, (see pictures). LPA observed 2 separate bottles of prescription medications—one on the bookshelf and one on the dresser, and an aerosol can of ant spray and 3/4 full bottle of nail polish remover on the dresser and accessible to clients in care, (see pictures). LPA observed more than 17 instances of chemicals, detergents, and/or toxic substances accessible to clients in care, (see pictures). Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed 3 of 3 client bathrooms without paper products available for clients to dry their hands and one with a towel hanging in it, (see pictures). 3 of 3 client bathrooms were observed with a rust-colored ring in the toilet bowel of each, dark mold and mildew in the showers and dust and debris on the counters and floors, (see pictures). LPA observed a supply of clean linens available to clients. Clients' bedrooms were inspected and had all of the required furnishings as required in Title 22 regulations. LPA observed uncovered trash cans in client bathrooms, bedrooms, and in the eating area of the facility. Cabinets containing cleaning supplies and other items that could pose a risk were unlocked on at least 3 instances, (see pictures). LPA advised S1 and Licensee to ensure all toxins, cleaning supplies, detergents, and chemicals always remain inaccessible to clients. Facility has at least two days of perishable food and a supply of non-perishable foods. LPA observed at least 10 instances of expired food in the cupboards available to clients in care, (see pictures). LPA observed 2 instances of prepared food left uncovered in the refrigerator, (see pictures).
Medications were centrally stored and locked. However, LPA observed more than 10 instances of prescription medication, over-the-counter medication, and supplements accessible to clients in care, (see pictures). There is an unshaded outdoor patio area with seating for clients in care. LPA observed a dryer, filing cabinet, and debris in the back yard, (see pictures).LPA advised Licensee to remove the items. LPA observed one backyard gate obstructed with board, stone, and containers, and the other backyard gate locked with padlock, (see pictures). LPA informed Licensee that the gates need to be free from obstruction and the lock needs to be removed. LPA observed a locked storage shed in the backyard but was unable to inspect it, because Licensee stated they did not have a key for it at the facility, (see pictures). LPA did not observe an activity schedule, menu, personal rights signage or the required CCLD reporting poster in the facility. ...continued from LIC809C...
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
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: 08/15/2024
NARRATIVE
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***AMENDED***Continued from LIC809C... LPA was informed the facility does not have an internet access device available to clients in care. The facility phone was tested an operable during inspection. Facility's fire extinguisher was observed charged and was last serviced July 2024. Smoke and Carbon Monoxide detectors were tested and operational during inspection. Facility conducts regular monthly disaster drills, with the most recent drill conducted July 2024. LPA observed facility's emergency disaster plan which was last updated 2022. LPA did not observe a supply of PPE or emergency supplies present in the facility. LPA observed a first aid kit but advised Licensee to replenish it.
At approximately 2:00 PM, LPA reviewed five (5) staff files, six (6) client files, and T1’s required paperwork. Five (5) of five (5) staff files reviewed were missing one or more required documents: S1 and Staff 3-Staff 5 (S3-S5) were missing the personnel record/job application (LIC501) and first aid training certification; and Staff 2-Staff 5 (S2-S5) were missing a health screening (LIC503) and proof of negative TB results. Two (2) of six (6) client files reviewed were missing one or more of the required documents: Client 6 (C6) was missing the Medical Assessment/Physician’s Report (LIC602) and proof of negative TB results. Client 3 (C3) was missing the Personal Rights document. Six (6) out six (6) client files reviewed had all the remaining required documents. Licensee states they coordinate medical and dental visits for the clients and takes them to their appointments.
At approximately 5:00 PM, LPA reviewed medications and medication records which are not maintained in compliance with regulation. Facility does not manage P&I for clients in care.
Nine (9) citations and Eighteen (18) technical violations were issued during today's inspection. (See LIC809Ds and LIC9102s). Additionally, a citation for records not being available at facility was issued as a part of today's separate case management visit. (See the corresponding LIC809 Case Management and LIC809D).
LPA informed Licensee that CCL will be scheduling an informal meeting in the regional office to discuss today's inspection and additional citations and civil penalties may be issued at that time.
Updated copies of the following documents are to be submitted to CCL within 30 days of this visit:
LIC610D – Emergency Disaster Plan
LIC500 – Personnel Record
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, may result in a civil penalty assessment.
Exit interview conducted with Licensee and Appeal rights were given. Signature on form 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
LIC809 (FAS) - (06/04)
Page: 3 of 26
Document Has Been Signed on 08/15/2024 09:06 PM - It Cannot Be Edited


Created By: Julie Florio On 08/15/2024 at 07:42 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85087(a)(3)
Building and Grounds
(3) No room commonly used for other purposes shall be used as a bedroom for any person.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and interview the licensee did not comply with the section cited above in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee to submit a self-certification that the sleeping area has been removed to CCL by POC due date 8/16/2024.
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in more than 17 instances which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee to submit a self-certifaction that all disinfectants, cleaning solutions, and poisons are inaccessible to residents in care to CCL by POC due date 8/16/2024.
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)
Page: 2 of 25
Document Has Been Signed on 08/15/2024 09:06 PM - It Cannot Be Edited


Created By: Julie Florio On 08/15/2024 at 07:42 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(i)
Building and Grounds
(i) The items specified in Section 80087(g) above shall not be stored in food storage areas or in storage areas used by or for clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in ensuring medication is not stored which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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2
3
4
Licensee to submit a self-certifaction that medications will not be stored in the facility refrigerator where food is stored to CCL by POC due date 8/16/2024.
Type A
Section Cited
CCR
80066(a)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 6 out of 6 staff records reviewed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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2
3
4
Licensee to submit a self-certifaction that they will ensure all required staff documentation is present at the facility at all times to CCL by POC due date 8/16/2024.
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)
Page: 3 of 25
Document Has Been Signed on 08/15/2024 09:06 PM - It Cannot Be Edited


Created By: Julie Florio On 08/15/2024 at 07:42 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 5 out of 6 staff records reviewed missing proof of a current first aid certifaction which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee to submit self-certification that all staff requiring first aid certification will be registered for training within 7 days to CCL by POC due date 8/16/2024.
Type A
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring all staff and clients have prrof of negative TB results present in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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2
3
4
Licensee to submit a self-certification that they will ensure each staff and client in care has proof of a negative TB result to CCL by POC due date 8/16/2024.
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)
Page: 4 of 25
Document Has Been Signed on 08/15/2024 09:06 PM - It Cannot Be Edited


Created By: Julie Florio On 08/15/2024 at 07:42 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

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(d)(1)
Client Medical Assessments
(d) In addition to Section 80069(c), the medical assessment for clients in ARFs shall include the following: (1) A physical examination of the person, indicating the physician's primary diagnosis and secondary diagnosis, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, and record review, the licensee did not comply with the section cited above in ensuring that all clients in care have a medical assement at facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
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2
3
4
Licensee to submit self certification that clients missing medical assessments have been scheuled to have said assements to CCL by POC due date 8/16/2024.
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
1
2
3
4
Based on observation and interview, the licensee did not comply with the section cited above in more than 10 instances of medications found accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee to submit a self-certifaction that all medication are inaccessible to residents in care to CCL by POC due date 8/16/2024.
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)
Page: 5 of 25
Document Has Been Signed on 08/15/2024 09:06 PM - It Cannot Be Edited


Created By: Julie Florio On 08/15/2024 at 07:42 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

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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above as evidenced by grease splattered on stove and hood, cabinets and floors with dust, build up, and splattered liquids, as well as hair, and debris throughout the facility. LPA observed 3 client restrooms with mildew and mold in showers, toilet bowl in each with rust colored ring, and vents covered with a thick layer of dust which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/13/2024
Plan of Correction
1
2
3
4
Licensee to submit pictures that the cited deficiency areas have been brought into compliance by POC due date of 9/13/2024.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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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