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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803572
Report Date: 04/29/2022
Date Signed: 04/29/2022 12:39:54 PM

Document Has Been Signed on 04/29/2022 12:39 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./SALGADO BOARD & CARE HOMEFACILITY NUMBER:
486803572
ADMINISTRATOR:ROSE SALGADOFACILITY TYPE:
735
ADDRESS:570 INVERNESS DRIVETELEPHONE:
(707) 315-4838
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 10CENSUS: 10DATE:
04/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rose Salgado, AdministratorTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and was greeted by client (C1). LPA was informed by C1 that staff S1 had left the facility and was not sure if any other staff was present. LPA contacted Administrator, Rose Salgado and LPA was informed that staff (S2) was in the facility. LPA asked C1 to check for staff S2 and LPA found that S2 had been asleep with all clients unattended. LPA interviewed S2 and S2 admitted to have been sleeping while clients were found both inside and out of the facility with no supervision. The facility currently provides care for client (10) clients 7 of which were present and 3 of which were out in the community at the time of visit.

LPA arrived at the facility and had temperature checked and logged. LPA continued with a tour of the facility with Administrator and facility staff; facility was found to be clean and at a comfortable temperature. LPA observed a large wooden board covering the emergency exit along the facility side yard which serves as a fire hazard. The wooden board was immediately removed by the Administrator. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 2/16/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were not stored properly as per regulations on this day at the time of the visit. Multiple leftover food items in containers were not labeled by date. Bleach powder cleaning supply was found unsecured under the kitchen sink and was immediately removed. There was a supply of hygiene products and paper products available for clients. All client’s bedrooms have lighting & appropriate furnishings. Hot water measured between 109.2 and 109.4 degrees F which is within Title 22 regulations of 105 to 120 degrees F in faucets used by clients. All staff have updated 1st Aid & CPR Training on file.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/29/2022
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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: E.R. SALGADO,INC./SALGADO BOARD & CARE HOME
FACILITY NUMBER: 486803572
VISIT DATE: 04/29/2022
NARRATIVE
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During the tour of the facility LPA observed a strong smell of urine in client bathroom #1. LPA was informed that staff are to clean the restrooms in the morning but was not completed today. LPA also observed shower curtains in client bathrooms #1 & #2 to have mildew and requires cleaning or replacing.

LPA requested the following documents be sent to CCL by COB 5/13/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate(s)
Copy of Certificate of Liability Insurance

Infection Control:
Facility has submitted a mitigation program plan which has been approved. All staff and clients have been vaccinated with no reported or observed symptoms. Posters have been placed at the front door, and facility has a station at main entrance with a sign in, hand sanitizer and other items designated for visitors and staff. Staff are screened for temperature and symptoms on a daily basis and clients are screened on a daily basis.

***Civil Penalties assessed in the amount of $1000.00 for immediate violation of regulations 80087(c) Buildings & Grounds for obstructed emergency exits and 80078(a) Responsibility for Providing Care & Supervision for 7 out of 10 clients left unattended.

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. Appeal Rights Given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5
Document Has Been Signed on 04/29/2022 12:39 PM - It Cannot Be Edited


Created By: Dominic Tobola On 04/29/2022 at 11:12 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./SALGADO BOARD & CARE HOME
FACILITY NUMBER: 486803572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 wooden board obstrucing exit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2022
Plan of Correction
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Licensee failed to ensure all exits were free from obstruction. The wooden board covering facility side yard exit was immediately removed. LPA explained to Licensee the fire and safety risks the items poses. Licensee agrees to review regulation 80087(c) with all staff and submit a Proof of Corrections LIC9098 ensuring facility stays in compliance.
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
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 powder bleach cleaning supply located under the facility kitchen sink. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2022
Plan of Correction
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Licensee failed to ensure toxins and other cleaning supplies were not accessible to clients in care. Licensee immediately removed the cleaning supply and placed in a secured location. Licensee agrees to review regulation 80087(g) with all staff and submit a Proof of Corrections LIC9098 ensuring facility stays in compliance
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 04/29/2022 12:39 PM - It Cannot Be Edited


Created By: Dominic Tobola On 04/29/2022 at 11:12 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./SALGADO BOARD & CARE HOME
FACILITY NUMBER: 486803572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80078(a)
Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's need.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with staff S2 and client C1, the licensee did not comply with the section cited above in which 7 out of 10 cleints in the facility were left unattended and unsupervised, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/02/2022
Plan of Correction
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Licensee is to ensure that there is sufficient staff to supervise clients in care and ensure health and safety of the clients. Licensee to submit an updated LIC500 along with staff work hours and update facility's policy and procedures regarding personnel practices and ensure clients are not left unattended and submit to CCL by 5/2/2022. ***Immediate civil penalty in the amount of $500 were issued during today's visit for 7 of 10 clients left unattended in violation of regulation 80078 Responsibility for Providing Care and Supervision.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/29/2022 12:39 PM - It Cannot Be Edited


Created By: Dominic Tobola On 04/29/2022 at 11:12 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./SALGADO BOARD & CARE HOME
FACILITY NUMBER: 486803572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/29/2022

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 observation, the licensee did not comply with the section cited above. LPA observed client bathroom #1 to have a strong smell of urine. LPA also observed shower curtains in client bathrooms #1 & #2 to have mildew which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Licensee failed to ensure facility was kept clean, safe and sanitary at all times. Licensee agrees to deep clean client restrooms and replace shower curtains. Photo evidence is to be submitted to CCLD by POC due date 5/9/2022.
Type B
Section Cited
CCR
80076(a)(1)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan -Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 leftover food items that were not properly labeled with a date which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Licensee failed to ensure food is safe and of quality and in quantity neccesary to meet needs of clients. Licensee agrees to hold in-service meeting with staff to review regulation 80076 and the facility food storage policy and submit a Proof of Corrections LIC9098 ensuring facility stays in compliance.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022


LIC809 (FAS) - (06/04)
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