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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600432
Report Date: 07/24/2025
Date Signed: 07/24/2025 02:29:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2025 and conducted by Evaluator Yi Sam Jian
COMPLAINT CONTROL NUMBER: 14-AS-20250527120745
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: 16DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anna Villanuva-AoayTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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-Licensee did not ensure sufficient food items were available at the facility for residents in care
-Staff did not provide personal care items to resident in care
-Staff's behavior poses a risk to residents in care
INVESTIGATION FINDINGS:
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On 07/24/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver conclusionary finding for this complaint received by the Department. LPA was greeted by administrator, Anna Villanuva-Aoay, and explained the purpose of the visit.

Regarding the allegations that did not ensure sufficient food items were available at the facility for residents in care, Staff did not provide personal care items to resident in care, and Staff's behavior poses a risk to residents in care, the Department has investigated the above allegations. Based on observations and interviews with staff and residents during the investigation, it was determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED.

The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Report is reviewed with administrator and a copy is provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 14-AS-20250527120745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2025
Section Cited
CCR
87307(a)(3)(D)
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Personal Accommodations and Services(a)(3)Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident(D)Hygiene items of general use such as soap and toilet paper
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The administrator will develop a written plan to ensure that residents are provide with hygiene items upon request. The administrator will submit a copy of the plan to CCL by POC due date.
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This requirement was not met, as evidenced by observations, resident and staff interviews indicating that the licensee failed to provide personal hygiene items to residents upon requested. This deficiency poses a potential health and safety risk to residents in care.
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Type B
07/31/2025
Section Cited
CCR
87555(b)(26)
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General Food Service Requirements(b)(26)Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
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The administrator will develop a written plan to ensure that Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premise. The administrator will submit a copy of the plan to CCL by POC due date.
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This requirement was not met, as evidenced by LPA observations indicating an insufficient amount of food available for the 17 residents at the time of inspection. This deficiency poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/27/2025 and conducted by Evaluator Yi Sam Jian
COMPLAINT CONTROL NUMBER: 14-AS-20250527120745

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: 16DATE:
07/24/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Anna Villanuva-AoayTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff did not ensure hot water was available at the facility for residents' use
INVESTIGATION FINDINGS:
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THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 07/24/2025.
On 07/24/2025, LPA arrived at the facility to deliver conclusionary finding for this complaint received by the Department. LPA was greeted by administrator and explained the purpose of the visit.

Regarding the allegation that Staff did not ensure hot water was available at the facility for residents' use, the Department has investigated the above allegation, LPA observed and measured water temperature to be compliant during the visit.

The allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated. Report is reviewed with administrator and a copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20250527120745
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2025
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents(a)(1)To be accorded dignity in their personal relationships with staff. This requirement was not met, as evidenced by resident and staff interviews indicating licensee was disruptive to residents in care with loud music and had yelled at residents.
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The administrator will develop a written plan to ensure residents’ dignity and respectful treatment are upheld, addressing issues such as loud music and yelling. A copy of the plan will be submitted to CCL by the POC due date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4