385600432-8-11-2023-14-AS-KHOS-CURKN7-20230816080236

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600432
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:28:11 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2023 and conducted by Evaluator Komal Charitra

COMPLAINT CONTROL NUMBER: 14-AS-20230807114635

FACILITY NAME:	PSALM RESIDENTIAL CARE HOME		FACILITY NUMBER:	385600432
ADMINISTRATOR:	ENCARNACION, WILLIAM, S		FACILITY TYPE:	740
ADDRESS:	565 GROVE ST		TELEPHONE:	(415) 621-8505
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	22	CENSUS: 16	DATE:	08/11/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee/Administrator, William Encarnacion		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility allowed excluded individual into facility
Resident selling drugs to another resident

INVESTIGATION FINDINGS:

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On August 11, 2023, Licensing Program Analysts (LPAs) Komal Charitra and John Calandra conducted an unannounced 10-day complaint visit. LPAs met with Caregiver, Jay Tacras and Licensee/Administrator, William Encarnacion joined shortly thereafter.

Regarding the allegation facility allowed excluded individual into the facility, according to the reporting party, an excluded individual is coming inside the facility.

During the investigation, LPA interviewed the Licensee, facility staff and residents. According to the Licensee, it was acknowledged that he is aware that an excluded individual is coming to the facility everyday, multiple times a day and has contact with the residents in care, however does not contact the excluded individuals' responsible party. In addition, according to the Licensee, he indicated that he instructed his staff that if the excluded individual comes to the facility, to either call the police or ask the excluded individual to leave.

According to 4/5 residents interviewed, they have all seen the exluded individual yesterday on 8/10/2023. Furthermore, during the visit today, LPAs observed exlcuded individual sitting outside the facility.

CONT. TO 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 14-AS-20230807114635

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PSALM RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600432
	VISIT DATE: 08/11/2023

NARRATIVE

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Regarding the allegation that resident is selling drugs to another resident, according to the reporting party, Resident 1 (R1) is selling meth to Resident 2 (R2).

During the investigation, LPA interviewed the Licensee, facility staff, R1 and R2. The Licensee denied this allegation and indicated he has not witnessed residents selling drugs to other residents at the facility. LPAs interviewed R1 and R2. R1 refused to communicate with LPAs. According to R2, he/she confirmed and admitted that he/she is receiving drugs from R1.

Therefore, based on the interviews conducted and information collected, the above allegations are determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Licensee and a copy is provided with appeal rights. Civil penalties are also provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20230807114635

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 08/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/12/2023 Section Cited CCR 87205(a-b)	1 2 3 4 5 6 7	87205 Accountability of Licensee Governing Body: (a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility and establish policies concerning its operation in conformance with these regulations and the welfare of the individuals it serves. (b) If the licensee is a corporation or an association, the governing body shall be active, and functioning in order to assure accountability. Violation of this regulation is not met as evidence by	1 2 3 4 5 6 7	Licensee/Administrator to submit a written plan of action describing how to ensure excluded individual is not coming to the facility and having contact with residents in care.
	8 9 10 11 12 13 14	Based on information collected, the Licensee acknowledged that he is aware that an excluded individual is coming to the facility everyday, multiple times a day and has contact with the residents in care, however is not contacting the excluded individuals' responsible party.	8 9 10 11 12 13 14	An immediate civil penalty of $250 is being issued for a repeat violation within 12 months. Deficiency was issued on 5/16/2023 and will be issued again on 8/11/2023.
Type A 08/12/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator to submit a written plan of action describing how to ensure safe and comfortable environment for residents in care if excluded individual is coming to the facility.
	8 9 10 11 12 13 14	Based on interviews conducted and information collected, interviewed staff and 4/5 residents indicated that an excluded individual is coming to the facility and is having contact with the residents.	8 9 10 11 12 13 14	An immediate civil penalty of $250 is being issued for a repeat violation within 12 months. Deficiency was issued on 5/16/2023 and will be issued again on 8/11/2023.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20230807114635

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 08/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/12/2023 Section Cited CCR 87405(b)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties: (b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/ Administrator to submit a written plan in writing in regards to how to carry how responsibilities as an administrator to ensure residents are safe and maintain a comfortable environement
	8 9 10 11 12 13 14	Based on interviews conducted, administrator is aware that an excluded individual is coming to the facility, however failed to be responsible and notify appropriate parties and seek help.	8 9 10 11 12 13 14	An immediate civil penalty of $250 is being issued for a repeat violation within 12 months. Deficiency was issued on 5/16/2023 and will be issued again on 8/11/2023.
Type A 08/12/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/administrator to submit a written plan in writing describing facility protocols regarding drug use. Administrator/Licensee to submit a plan in writing regarding who to contact if facility staff report drug use at the facility
	8 9 10 11 12 13 14	Based on interviews conducted, R2 admitted and confirmed that R1 is providing him/her drugs at the facility	8 9 10 11 12 13 14	An immediate civil penalty of $250 is being issued for a repeat violation within 12 months. Deficiency was issued on 5/16/2023 and will be issued again on 8/11/2023.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023

LIC9099 (FAS) - (06/04)

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