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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601466
Report Date: 10/29/2021
Date Signed: 10/29/2021 12:14:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:HOUSE OF PSALMS ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
015601466
ADMINISTRATOR:CHEN, YANLINGFACILITY TYPE:
740
ADDRESS:1525 7TH AVENUETELEPHONE:
(510) 251-2521
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:23CENSUS: 19DATE:
10/29/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Yanlin Chen, AdministratorTIME COMPLETED:
12:15 PM
NARRATIVE
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On 10/29/2021 at 9:20 AM, Licensing Program Analysts (LPAs) L. Francisco and G. Clark arrived unannounced to conduct Infection Control Inspection. LPAs met with Administrator, Yanling Chen and explained the purpose of the visit.

During the Infection Control Inspection, LPAs toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and outdoor area. Facility has a sufficient 2-day perishable and one week non-perishable food supply. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed. Cough/sneeze etiquette and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. PPEs are stored in a central location and easily accessible for staff. Facility has a mitigation plan on file.

The following deficiency was observed:
-At approximately 10:10am, LPAs were unable to unlock the front gate entrance from inside of the facility. LPAs observed a black cord attached to the handle from other side of the gate. Staff demonstrated opening the door by pulling the cord.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021
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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HOUSE OF PSALMS ASSISTED LIVING FOR SENIORS
FACILITY NUMBER: 015601466
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways 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. LPAs observed front gate does not open from the inside of facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2021
Plan of Correction
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Administrator will review regulation and submit a self-certification letter that front gate is easily opened from the inside.
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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2021
LIC809 (FAS) - (06/04)
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