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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600432
Report Date: 05/16/2023
Date Signed: 05/16/2023 12:26:51 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
01/06/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230106144444
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: 15DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/Administrator, William EncarnacionTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Residents overdosed on drugs
Facility failed to report incident to CCL
Facility staff took resident's money
Facility administrator failed to follow Title 22 licensing requirements
INVESTIGATION FINDINGS:
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On May 16, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Jaime Vado conducted an unannounced complaint visit with Investigator Victoria McIntosh to deliver findings for the above allegations. LPAs and Investigator met with Licensee/Administrator, William Encarnacion and explained the purpose of the visit.

Regarding the allegation residents overdosed on drugs, according to the reporting party, it was reported that two residents, Resident 1 (R1) and Resident 2 (R2) overdosed on Fentanyl.

During the investigation, the Department conducted interviews, collected documents, reviewed R1 and R2’s medical records, and conducted a facility sweep. Based on interviewed conducted, the Licensee, a staff member (S1), and two other residents, stated that R1 and R2 use drugs (fentanyl, methamphetamine, and marijuana) at the facility, amongst other residents. In addition, during a facility sweep conducted by the Department, drug paraphernalia was observed in the resident’s rooms, such as pipes.

According to the Licensee, he acknowledged that he is aware of the residents using drugs at the facility, has admitted to being aware of R1 using crack cocaine and findings a pipe in R1's room. The Licensee indicated he was attempting to evict R1 after finding out R1 does crack cocaine, however, did not follow through with it.

Based on the file reviewed, documents indicate that R1 had a relationship with drugs starting in 2019. According to the Licensee, he acknowledged that he attempted to evict R1 due to drug use, however, did not go through with it. According to medical records reviewed, on 12/29/22, R1 was transported to CPMC and tested positive for fentanyl. (Continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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 6
Control Number 14-AS-20230106144444
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: 05/16/2023
NARRATIVE
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Furthermore, according to medical documents reviewed, on 12/27/22, R2 was transported to CPMC for suffering possible seizure, however R2’s doctors believed R2 was having an overdose on fentanyl rather than having a seizure which the facility stated. R2 was found to test positive for fentanyl and benzodiazepine on a urine drug screen.

Based on observations, interviews conducted, and documents reviewed during this investigation, the preponderance of evidence standard has been met. Therefore, the allegation that residents overdosed on drugs is determined to be SUBSTANTIATED as the Licensee/Administrator admitted he was aware that residents were using drugs in the facility, however failed to take action or provide additional supervision to the residents in care.

Regarding the allegation that facility failed to report incident to CCL, according to the reporting party, R1 was hospitalized on 12/29/22 and R2 was hospitalized on 12/27/22 as one had a seizure and the other resident couldn’t breathe. In addition, the reporting party indicated, he/she is unsure if the facility reported this incident to CCL.

During the investigation, LPA requested copies of the incident reports that were submitted to CCL with the fax confirmation sheet. Based on the incident reports reviewed, on 12/29/22, R1 was hospitalized due to not being able to breathe. Licensee did not submit an incident report for R1 till 1/12/23 when LPA requested for it. In addition, on 12/27/22, R2 was hospitalized due to a seizure. Licensee failed to submit an incident report till 1/12/23 when LPA requested for it.

Based on information collected and documents reviewed during this investigation, the preponderance of evidence standard has been met. Therefore, the allegation that facility failed to report incident to CCL is determined to be SUBSTANTIATED.

Regarding facility staff took resident’s money, according to the reporting party, Staff 2 (S2) wire transferred Resident 3’s (R3’s) money into S2’s bank account.

(Continue to 9099C Second Page)
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 14-AS-20230106144444
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: 05/16/2023
NARRATIVE
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On June 2, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced visit to deliver an amended 9099C and 9099D that was provided on May 16, 2023, by LPA Komal Charitra. LPA met with Licensee/Administrator, William Encarnacion and explained the purpose of the visit. This report is amended to correct staff identified on 9099C and correct the deficiency cited on 9099D.

During the investigation, LPA interviewed the Licensee and S1. According to the Licensee, on 8/14/2022, S1 called Licensee to notify him that S2 admitted to S1 that he/she was taking money from R3. On 8/15/22, S2 quit working at the facility. In addition, according to S3, he/she asked S2 and S2 admitted that he/she took R3's money

Based on information collected and interviews conducted during this investigation, the preponderance of evidence standard has been met. Therefore, the allegation that facility staff took resident’s money is determined to be SUBSTANTIATED.

Regarding the allegation facility administrator failed to follow Title 22 licensing requirements, according to the reporting party, he/she believes that the Licensee/Administrator is not qualified to run the facility.

During the investigation, the Department interviewed staff and Licensee. Based on interviews conducted, it was discovered that the Licensee/Administrator failed to conform with CCL regulations as Licensee was aware of the drug use at the facility, however, did not take action. In addition, the Licensee failed to notify CCL when he discovered S2 was taking money from R3.

Based on information collected and interviews conducted during this investigation, the preponderance of evidence standard has been met. Therefore, the allegation that facility allegation facility administrator failed to follow Title 22 licensing requirements is determined to be SUBSTANTIATED.

The deficiencies for the above substantiated allegations is cited in accordance with California Code of Regulations, Title 22, Division 6 and is noted on attached LIC 9099-D. Immediate Civil Penalty of $500 is assessed for violation resulting in death and serious bodily injuries. The Licensee was informed that additional civil penalties may be assessed. Report is reviewed with Licensee and a copy is provided with appeal rights. A copy of the civil penalty will be provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/06/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230106144444

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:
05/16/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/Administrator, William EncarnacionTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility failed to follow COVID-19 protocols
INVESTIGATION FINDINGS:
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On May 16, 2023, Licensing Program Analysts (LPA) Komal Charitra and Jaime Vado conducted an unannounced complaint visit with Investigator Victoria McIntosh to deliver findings for the above allegations. LPAs and Investigator met with Licensee/Administrator, William Encarnacion and explained the purpose of the visit.

Regarding the allegation that facility failed to follow COVID-19 protocols, according to the reporting party, facility staff does not screen visitors when they enter the facility.

During the investigation, LPA interviewed the Licensee/Administrator and reviewed facility’s COVID-19 screening log. According to the Licensee, visitors and clients are screened as they come into the facility by a staff. LPA observed the COVID-19 screening log for visitors and clients. Based on observations, clients and visitors are getting screened and are signing in prior to entering the facility.

Therefore, based on the documents reviewed and interviews conducted, the allegation that facility failed to follow COVID-19 protocols is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Licensee, William Encarnacion and explained the purpose of the visit.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 14-AS-20230106144444
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: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/17/2023
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

Violation of this regulation is not met as evidenced by:
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Licensee to submit a plan in writing to address how the facility will provide supervision to residents and enforce and monitor drug use at the facility. Licensee to submit a plan in writing regarding illegal drug use.
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Based on interviews conducted and information collected, the Licensee admitted to being aware of the drugs being brought into the facility and residents were using drugs, however failed to take action allowing residents to continue using drugs at the facility. In addition, due to lack of supervision, drugs were being brought into the facility and residents continued to use drugs. Furthermore, due to the drugs being brought into the facility, R1 overdosed on fentanyl resulting in a death and R2 overdosed on fentanyl resulting in a serious bodily injury.

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An immediate civil penalty of $500 is being assessed for violation resulting in death of a resident and serious bodily injuries
Type A
05/17/2023
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements:
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…

Violation of this regulation is not met as evidenced by:
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Licensee to read and acknowledge CCR 87211 Reporting Requirements. Licensee to conduct in-service training regarding reporting to CCL and all required parties within regulatory time-frame. In-service training will be conducted with staff and a copy of sign-in sheet to be provided to CCL.
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Based on information collected and interviews conducted, the Licensee failed to report two incidents (12/27/22 and 12/29/22) to CCLD until 1/12/23, however Licensee only submitted the two incident reports because LPA requested for them.
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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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20230106144444
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: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/17/2023
Section Cited
HSC
1596.8897(a)(5)
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1596.8897 Prohibited positions or employment; grounds; notice; removal; appeal; petition for reinstatement: (a) The department may prohibit any person from being a member… of the licensee or a licensee from employing, or continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of a licensed facility by, any employee.. who has: (5) Engaged in acts of financial malfeasance concerning the operation of a facility, including, but not limited to, improper use or embezzlement of client moneys…

Violation of this regulation is not met as evidenced by:
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Licensee to develop a plan in writing addressing how Licensee will safeguard resident's moneys and personal belongings. Licensee to conduct in-service training with staff to educate them regarding safeguarding resident's money
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*AMENDED* Based on interviews conducted and information collected, S1 notified the Licensee that S2 admitted to taking R3’s money and quit working at the facility the next day. In addition, the Licensee acknowledged to not notifying CCL regarding this incident. Furthermore, S2 admitted to taking R3’s money to S1 and S3.
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Type A
05/17/2023
Section Cited
CCR
87405(b)
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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:
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Licensee shall develop a plan in writing describing the duties and responsibilities of the Licensee/Administrator to ensure that proper action is taken when serious incident occurs. Licensee to submit training regarding Mandated Reporting
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Based on the information collected and interviews conducted, the Licensee failed to report serious incident to CCL in a timely manner. In addition, the Licensee admitted to being aware that residents were using drugs in the facility, however failed to take action. Nevertheless, the facility Licensee failed to have the responsibility to carry out the policies of the licensee as two residents overdosed on fentanyl in the facility.
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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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6