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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019201331
Report Date: 08/05/2024
Date Signed: 08/05/2024 12:30:37 PM


Document Has Been Signed on 08/05/2024 12:30 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:HOUSE OF PSALMS ASSISTED LIVING FOR SENIORSFACILITY NUMBER:
019201331
ADMINISTRATOR:OGUNDELE, BAMIKOLEFACILITY TYPE:
740
ADDRESS:1525 7TH AVETELEPHONE:
(925) 208-9250
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY:23CENSUS: 21DATE:
08/05/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Bamikole Ogundele, Applicant/AdministratorTIME COMPLETED:
12:15 PM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 23
Census (if any clients in care): 21
COMP II Participants: Bamikole Ogundele, Applicant/Administrator
Interview Method: Telephone interview

On August 5, 2024 at 10:45 AM, applicant/administrator participated in COMP II. Identification of the applicant/administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant/administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained.

During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and .
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Applicant/Administrator. Copy of report sent via email and informed to return signed copy to CAB by end of business day today.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2024
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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