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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803572
Report Date: 02/24/2023
Date Signed: 02/24/2023 10:46:12 AM

Document Has Been Signed on 02/24/2023 10:46 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
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: 9DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Rose Salgado, LicenseeTIME COMPLETED:
11:00 AM
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On 2/24/2023, Licensing Program Analyst (LPA) D. Tobola conducted an unannounced Annual Required – 1 yr. Infection Control inspection for this facility and met with Lead Staff, Loreto Rubin and Licensee, Rose Salgado. The facility currently provides care for 9 clients, 7 of which were present at the time of visit and 2 of which were attending day program.

LPA continued with a tour of the facility with Lead Staff & Licensee; facility was found to at a comfortable temperature with all exits free from obstruction. Client’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher located in the kitchen and was found to be last charged on 8/5/2022 at the time of the visit. Smoke detectors in client bedrooms and throughout were inspected and found to be in working order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with balanced meals and alternative options for clients. LPA conducted a sample file review and found all staff to have current CPR and 1st Aid certification on file.

Toxins are stored in a locked cabinets located in garage as well as designated closets and staff area and all found to be secured. There was a supply of hygiene products and paper products available and kept in each client's respective bedrooms. Facility has restrooms equipped with paper towel and soap dispensers. All client bedrooms have lighting & appropriate furnishings. Medications and facility records are stored in designated cabinets located in the staff office and found to be secured. Clients were observed to be in their respective bedrooms resting, socializing with one another or on their phones.

LPA observed several items in need or repair or cleaning. In client bedroom 1 out of 1 damaged window blinds need repair or replacement. In addition, a water leak in the ceiling of client bathroom was observed. Facility is currently in the process of inspecting and repairing leaks due to recent weather. The ceiling leak was found to to drip directly in the the restroom sink and not damaging or effecting any other part of facility.

Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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: 02/24/2023
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During the inspection LPA found a scent of smoke from client bedroom. Licensee stated that they have been working with client and redirecting them to smoke outside. Licensee hold client cigarette packs for clients to request, however, clients are able to leave the facility unassisted and found to have purchased their own tobacco items which are sometimes kept by clients. LPA also observed fixtures, shelving and window screens and closets in need of deep cleaning. Lastly, LPA observed two lights located in front doorway and hallway are in need of replacement. Licensee agrees to fix items observed in client bedrooms and throughout the facility and send photo proof of corrections to CCLD.

Administrator, Rose Salgado's Administrator Certification 6024223735 was received by the Department on 1/10/2023 and is currently on the pending application list.

Infection Control:
Facility has completed an Infection Control Plan and submitted CCLD for review. All clients and staff are vaccinated with no symptoms. Posters have been posted throughout the facility for staff and clients ensuring COVID procedures. Facility has a station at main entrance for screening, hand sanitizer and other items designated for visitors and staff. Staff and clients are observed for symptoms and temperature on daily basis or based on change of condition.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal Rights Given.

LPA requested the following documents be sent to CCL by COB 3/10/2022:



LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility client’s/client’s
Copy of Administrator Certificate(s)
Copy of Liability Insurance
Copy of Surety Bond
Updated Licensee & Staff Contact Information
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/24/2023 10:46 AM - It Cannot Be Edited


Created By: Dominic Tobola On 02/24/2023 at 10:31 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: 02/24/2023

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 observation, the licensee did not comply with the section cited above in several items in need of repair including, lights in faciltiy hallway and front door, leak in client restroom, repairs to window blinds and general cleaning of client bedroom fixtures and furniture, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/10/2023
Plan of Correction
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Licensee agrees to address each item listed in statement and provide photo proof of corrections to CCLD showing repairs and cleaned areas of the facility. Plan of Corrections to be submitted by POC due date 3/10/2023.
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: 02/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2023


LIC809 (FAS) - (06/04)
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