<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 12/27/2024
Date Signed: 12/30/2024 01:42:36 PM

Document Has Been Signed on 12/30/2024 01:42 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:
12/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Anna Villanuva-AoayTIME VISIT/
INSPECTION COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
*****This is an amended report from original dated 12/27/2024 earlier today*************

Licensing Program Analyst (LPA) Yi Sam Jian met with Administrator, Anna Villanuva-Aoay, (S1) for this case management visit. Purpose of the visit explained. On December 24, 2024, the Department received a death regarding an elderly resident (R1). At 7:30AM, a staff person found R1 in his bedroom in bed and R1 appeared pale and unresponsive. Staff called another staff, administrator arrived, and 911 was called. Paramedics arrived and took R1s vital signs and pronounced resident dead. Regional office is in process of gathering additional information and to obtain the cause of death.

LPA gathered information and reviewed R1s file. The following documents were obtained during the visit regarding R1:

· Physician’s Report dated 10/10/2023

  • Functional Capability Assessment

· Resident Appraisal dated 8/2017

(Continued on next page 809-C)

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 12/27/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on review of documents and information obtained from staff interviews, the following was determined: the last time staff interacted with R1 was the evening before on 12/23/2024 at approximately 9:00PM as R1 was reading a book before going to sleep. Interviews conducted indicated no unusual concern about R1 and everything appeared normal. The following morning on 12/24/2024, during morning check at approximately 7:30AM, staff person, Elaine Jose (S1) found R1 in bed and he appeared to be pale and unresponsive. S1 then went to alert another caregiver Jay Tacras (S2). S2 performed CPR on R1 attempting to revive him however was unsuccessful. At approx. 7:45AM, the administrator arrived at facility and assessed R1; 911 was then called. Paramedics arrived shortly after called and attempted CPR. Attempts to revive R1 were unsuccessful and R1 was declared deceased by paramedics. Staff called the family and responsible party and informed of the situation. The immediate cause of death is unknown currently. LPA requested facility to obtain the death certificate and forward to the licensing office for further review. After death certificate received, there may be further follow up regarding this incident. The death certificate shall be sent to the licensing office by January 4, 2025.

This report is emailed to facility representative and a copy of this report must be made available for public review upon request.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2