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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 09/30/2024
Date Signed: 09/30/2024 11:51:02 AM


Document Has Been Signed on 09/30/2024 11:51 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:ANNA VILLANUEVA-AOAYFACILITY TYPE:
740
ADDRESS:565 GROVE STTELEPHONE:
(415) 621-8505
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:22CENSUS: 15DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Anna VillanuevaTIME COMPLETED:
12:15 PM
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On 09/30/2024, Licensing Program Analyst (LPA) Grace Donato and LPA Yi Sam Jian conducted an unannounced annual inspection. LPA met with administrator, Anna Villanueva. LPA explained the purpose of the visit.

The ground level had 10 bed rooms for residents, and 3 bathrooms, 1 toilet room, living room, office, 1 staff room, kitchen, patio courtyard, closet, and furnace room.

Backyard was fenced, secured, and in good condition. All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed.

Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety.

Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Facility has a written emergency disaster plan. Licensee stated there are no firearms or ammunition at the facility. Licensee has at least one completed first aid kit located in the office.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Facility provided a copy of Liability insurance and updated sketch of the facility. No Deficiencies cited. Report reviewed and discussed with Anna Villanueva.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024
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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