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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 10/19/2021
Date Signed: 10/19/2021 12:59:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PSALM RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600432
ADMINISTRATOR:ENCARNACION, WILLIAM, SFACILITY TYPE:
740
ADDRESS:565 GROVE STTELEPHONE:
(415) 621-8505
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:22CENSUS: DATE:
10/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:William EncarnacionTIME COMPLETED:
12:30 PM
NARRATIVE
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On October 19, 2021, Licensing Program Analyst (LPA) Komal Charitra and Jaime Vado conducted an unannounced annual infection. Upon arrival, LPAs observed signage on the front door. LPAs were greeted by the Administrator, William Encarnacion and explained the purpose of the visit. LPA's temperatures were checked but were not screened at the entry point. The administrator was not able to provide screening log documentation for residents and visitors.

LPAs toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are not present: entry procedures and social distancing during meal time. Bathrooms are equipped liquid soap but LPAs also observed trash cans with no lids, bar soaps, and no paper towels.

COVID signs are observed in the bathroom, kitchen, and living room. LPAs advised Administrator that more signs regarding masking and social distancing should be posted in the long open hallway, hand-washing in all bathrooms, as well as cough etiquette signs throughout the facility. All rooms are occupied at the facility besides the vacant isolation room at the rear of the facility.

Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was was observed and complete. LPAs observed residents and staff wearing masks during the time of inspection.

The facility was not able to provide any documentation for the daily COVID-19 screening for the residents and staff members. Licensee admitted to LPAs that CPR/First Aid Cards have been expired for S1, S2, S3, and S4. According to administrator, all staff and residents are fully vaccinated.

Deficiencies of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PSALM RESIDENTIAL CARE HOME
FACILITY NUMBER: 385600432
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)


This requirement is not met as evidenced by: Licensee not being abe to provide LPAs with curret First Aid Cards. Licensee admitted that S1, S2, S3, and S4's First Aid Cards are expired.
Deficient Practice Statement
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Based on admission by the Licensee, staff first aid cards are not currrent, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2021
Plan of Correction
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Licensee to have staff train in First Aid and CPR. Plan to be received in RO.
Type B
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Licensee failed to provide dcumentation for daily resident, staff, and vistor questionnaire log;failed to enforce entrance screening procedures; failed to maintain paper towels in resident and staff bathrooms; trash bins observes to not having lids in resident bathrooms; failed to maintain social distancing during meal times.
POC Due Date: 10/26/2021
Plan of Correction
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The administrator/licensee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening for residents and staff members, COVID-19 Protocols, and maintaining social distancing in the facility
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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021
LIC809 (FAS) - (06/04)
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