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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 12/23/2024
Date Signed: 12/23/2024 07:22:18 PM

Document Has Been Signed on 12/23/2024 07:22 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:
12/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:ANNA VILLANUEVA-AOAYTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 12/23/2024, the Licensing Program Analyst (LPA) Yi Sam Jian arrived at the facility for an unannounced case management visit to follow up on an incident report submitted by the facility to the department on the same day. The report indicated that on 12/22/2024, R1 had left the facility, missed both breakfast and lunch, and suffered a fall outside. R1 was taken to St. Mary’s Hospital and returned to the facility by 2:00 PM on 12/22/2024, back to baseline. The LPA met with the Administrator, Anna Villanueva-Aoay, and explained the purpose of the visit.

Upon reviewing R1’s records, the LPA found that R1 is ambulatory. The Appraisal/Needs and Services Plan noted that R1’s physical health is to enjoy walking outside at baseline. The Physician’s Report indicated that R1 is "able to leave the facility unassisted" with no reported "wandering behavior." The Physician has cleared R1 to leave the facility unassisted. The Client Assessment Checklist in the admission also noted that R1 does not have an AWOL risk or wandering tendencies. During an interview with the Administrator, it was confirmed that R1 enjoys going outside for walks, and R1 did not suffer any major injury from the fall occurred outside the facility.

During the visit, the LPA observed that staff were actively monitoring the front door, and staff was signing in and out all individuals entering and exiting the facility.

No deficiencies were cited. This report was reviewed and discussed with the Administrator, and a copy was provided.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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