<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601466
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:18:16 PM


Document Has Been Signed on 10/10/2023 03:18 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, 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: 20DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Bamikole Ajibola Ogundele, new ownerTIME COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/10/23 at 11:00 AM, Licensing Program Analyst (LPA) G. Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with new owner Bamikole Ajibola Ogundele and explained the purpose of the visit. The facility’s fire clearance was approved for 23.

LPA toured the facility including but not limited to 3 residents’ rooms, bathrooms, multiple activity rooms, kitchen, common area and courtyard. There are no bodies of water observed. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. Hallway temperature was maintained at 76 degrees F. The hot water temperature at the kitchen sink were measured at 112.3 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care. Fire extinguisher was last serviced on 1/06/23. First Aid kit was observed to be complete.

At 11:30 a.m., LPA reviewed 5 residents records. At 1:05 p.m., LPA reviewed 5 staff records and 5 of 5 have current first aid training and associated to the facility. At 12:40 p.m., LPA reviewed a sample of resident’s medications.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/17/23: LIC 610E Emergency Disaster Plan

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: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1