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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803572
Report Date: 03/28/2025
Date Signed: 03/28/2025 03:41:47 PM

Document Has Been Signed on 03/28/2025 03:41 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:E.R. SALGADO,INC./SALGADO BOARD & CARE HOMEFACILITY NUMBER:
486803572
ADMINISTRATOR/
DIRECTOR:		ROSE SALGADOFACILITY TYPE:
735
ADDRESS:570 INVERNESS DRIVETELEPHONE:
(707) 315-4838
CITY:VALLEJOSTATE: CAZIP CODE:
94589
CAPACITY: 10CENSUS: 8DATE:
03/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:37 AM
MET WITH:Licensee/Administrator Rose SalgadoTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
NARRATIVE
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At approximately 11:40AM, Licensing Program Analyst (LPA) Ali Deniz arrived unannounced to conduct 1-Year Required inspection of this licensed adult care facility (ARF). LPA met with facility Licensee/Administrator Rose Salgado. The facility currently provides care for 8 clients, 6 of which were present at the time of visit. Facility is a 1 story building with 6 Resident bedrooms, 2 staff bedrooms, 3 bathrooms, and common spaces.

At approximately 12:15PM, LPA toured the building and grounds which was found to be clean and in good repair. LPA observed all walkways and exits to be unobstructed. All notices that are required to be posted have been posted and are in a highly visible area. LPA observed the amount of fresh and nonperishable foods is within regulation. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. However, kitchen cabinet under sink where is pots and pans are located was rotten due to water damage. Administrator stated that they are going to clean the cabinet today (Technical Assistant Given). Staff were in the process of cleaning up after breakfast at the time of this inspection. Toxins are stored in a locked housekeeping closet in the hallway.

Water temperature in the sink accessible to residents in care measured at 126 degrees F which is not within the allowable range of 105 to 120 degrees F (See LIC809-D page).

Fire extinguishers inspected were charged and last inspected on August 2022. However, the fire extinguishers’ pressure gauge was on green zone mark line (Technical violation Given). Carbon Monoxide and smoke detectors were present and in order. There was enough lighting in all common areas, resident rooms, and hallways. Medication is centrally stored and secure.

Continued on LIC809-C…
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/28/2025 03:41 PM - It Cannot Be Edited


Created By: Ali Deniz On 03/28/2025 at 03:02 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./SALGADO BOARD & CARE HOME
FACILITY NUMBER: 486803572

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the hot water being checked at 126 degrees Fahrenheit, which is not in compliance with regulation, the licensee did not comply with the section cited above which poses an immediate health, safety risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Licensee/Administrator to ensure the hot water is monitored and under 120.degrees Fahrenheit, and not to be under 105. degrees Fahrenheit. Monitor the hot water for a period of one week (7 days). Submit a copy of the hot water log, and a plan on how the facility will ensure the hot water is maintained in compliance with regulation. Submit plan of correction by with copy of hot water log and maintenance plan by 04/11/2025.
Type B
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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 3 staff did not have LIC501 Personel Records and LIC503 Health Screening in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/11/2025
Plan of Correction
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Licensee agrees to submit a copf of LIC501 Personel Records and LIC503 Health Screenin for the all employees working in the facility by the plan of correction date 04/11/2025
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Ali Deniz
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


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./SALGADO BOARD & CARE HOME
FACILITY NUMBER: 486803572
VISIT DATE: 03/28/2025
NARRATIVE
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Continued from LIC809…

At approximately 1:10PM, LPA reviewed 5 resident records and all found in order. 5 of 5 records contained current signed admission agreements and physician's orders on file. Medication records are thorough and contained physician's orders for each resident.



At approximately 2:05PM, LPA reviewed 3 staff records. 2 out of 3 records did not contain LIC501 Personal Records, LIC503 Health Screening, and documentation of completed training records as required per regulation (See LIC809-D page). Administrator have not been able to find required documents for S1 and S2. Evidence of current first aid and CPR training were current.

At approximately 2:30PM, LPA reviewed the facility emergency disaster plan with admin. The plan outlines evacuation routes, which are shown on facility sketch and has alternative meeting locations. Facility has supplies enough to operate for more than 72 hours in an emergency. Facility conducted and documented a disaster drill on 03/01/2025. LPA was presented with proof of current CPR & 1st Aid certification for staff. Administrator Certificate submitted for renewal for Rose Salgado #7034447735 on 1/17/2025.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by due date of 04/28/2025:

LIC 308 Designated
LIC 500 Personnel Records
LIC 610 Emergency Disaster Plan
Copy/Proof of Updated Certificate of Liability Insurance

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. Copy of report, LIC-809D, Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Ali Deniz
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
LIC809 (FAS) - (06/04)
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