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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 12/09/2024
Date Signed: 12/09/2024 03:00:08 PM

Document Has Been Signed on 12/09/2024 03:00 PM - 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/
DIRECTOR:		ANNA VILLANUEVA-AOAYFACILITY TYPE:
740
ADDRESS:565 GROVE STTELEPHONE:
(415) 621-8505
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY: 22CENSUS: 15DATE:
12/09/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:46 AM
MET WITH:Anna Villanuva-AoayTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 12/9/24, Licensing Program Analyst (LPA), Grace Donato conducted an unannounced case management- legal/non-compliance inspection to monitor the facility operation. LPA met with Administrator Anna Aoay and Licensee 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 new Administrator (ADM). ADM has been overseeing the running of the facilty, Licensee is available to help anytime needed and is still involved.

Facility has been constantly checking residents rooms if there are any forms of drug paraphernalia. Residents are all updated with their current annual check ups. If appointments are needed it is addressed by the ADM right away. Residents are also receiving medications on time. Medication cabinet is locked. LPA toured several rooms and observed no medication on site. Facility is reporting unusual incidents to Licensing on a timely manner.

Facility is clean and well maintained. Bathrooms are clean. No smell of smoke along the hallways. Hallways and rooms are mopped. All staff are currently fingerprinted and associated to the facility. Residents money are all kept separated.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 385600432
VISIT DATE: 12/09/2024
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For one resident (R1) who has a behavior of hoarding, facility has been folding the clothes and have provided bins for storage. If R1 wants to go over the clothing, R1 picks whatever clothes they want, the clothing are scattered and staff will fold them back and store it. Behavior has also been discussed to the case manager. Staff has provided documentation on how these are addressed.

Excluded person (P1) has not come in to the facility anymore and is aware that cops will be called. Residents are also aware not to let excluded individual in. P1 is being helped by a social worker but won't cooperate by living in an are where they can be placed. It was mentioned by the Licensee that P1 hangs out outside the house but doesn't get inside.

Facility is not a locked facility but during curfew, at 8pm, residents are home and doors are locked. Residents are still able to go out if they want to but has to let staff know.

Residents have been enjoying festivities as shown in photos provided by the administrator. LPA interviewed four residents and everyone said that they are happy here in the facility.

No citations issued today. Report is reviewed with and a copy is provided.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
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