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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601466
Report Date: 01/04/2023
Date Signed: 01/04/2023 11:53:47 AM


Document Has Been Signed on 01/04/2023 11:53 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, 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: 18DATE:
01/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Yanling Chen, AdministratorTIME COMPLETED:
12:00 PM
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On 1/04/23 at 11:00 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct Case Management visit due to a death report received on 11/26/22. LPA met with Administrator, Yanling Chen and explained the purpose of the visit.

During the case management visit LPA reviewed R1's file and interviewed the administrator (ADM).

R1 was admitted to the facility on 5/29/21 from a SNF with a primary diagnosis of a chronic heart condition and a DNR order. On 11/19/22 R1 was found by facility staff to be having difficulty breathing. 911 was called and R1 was sent out and admitted to Kaiser San Leandro. R1 was discharged from Kaiser on 11/23/22 with the advice to provide comfort care until arrangements could by made for hospice care. R1's Daughter/ responsible party agreed with this decision. ADM reported that she could not reach any hospice agency on 11/24/22 because of the Thanksgiving holiday.

On 11/25/22 at 3:43 p.m. R1 was found by facility staff to be not breathing and had no pulse. ADM called 911 and the Alameda County Sheriff immediately to report the death.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.



SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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