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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 05/23/2024
Date Signed: 05/23/2024 10:40:13 AM


Document Has Been Signed on 05/23/2024 10:40 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 14DATE:
05/23/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:47 AM
MET WITH:William EncarnacionTIME COMPLETED:
11:00 AM
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On 5/23/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Caregiver Jay Tacras and Administrator William Encarnacion followed after. LPA explained the purpose of the visit.

A non-compliance conference was held on June 15, 2023. During non-compliance meeting, the following violations were discussed Basic Services, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Incidental Medical and Dental Care, Criminal Record Clearance, Reappraisal, Personal Rights of Residents in All Facilities, Prohibited positions or employment; grounds; notice; removal; appeal; petition for reinstatement, Administrator Qualifications and Duties, Accountability of Licensee Governing Body, Observation of the Resident, Title 22, Division. 6, Chapter 8

During the visit, LPA reviewed the compliance plan with the Administrator. When LPA arrived, residents were resting in their bedrooms and some are watching tv in the living room. LPA toured the facility and it was observed that the flooring in certain areas are still fixed. Based on interview with Administrator, residents are regularly brought for check ups. There is still a scheduled NOC shift. There are constant check ups and reminders to resident to bring prohibited drugs in the facility. Administrator certificate has been updated. Everyone working in the facility are all associated and fingerprinted. All incident reports are being reported in a timely manner to Licensing.

LPA also confirmed and observed that an excluded individual is not at the facility anymore and staff are doing their best to keep said individual from entering the facility.

No citations issued today. Report is reviewed with and a copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
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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