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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 07/24/2025
Date Signed: 07/24/2025 11:49:05 AM

Document Has Been Signed on 07/24/2025 11:49 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/
DIRECTOR:		ANNA VILLANUEVA-AOAYFACILITY TYPE:
740
ADDRESS:565 GROVE STTELEPHONE:
(415) 621-8505
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY: 22CENSUS: 16DATE:
07/24/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Anna Aoay, Administrator & William Encarnacion, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On 7/24/2025, Licensing Program Analysts (LPA's) Tobola & Jian arrived unannounced for the purpose of conducting a quarterly probation visit and was greeted by Administrator, Anna Aoay. Licensee, William Encarnacion was contacted and arrived later in the visit. The facility had been placed on probation from April 22, 2025 to April 22, 2028 and is to comply with probation stipulation conditions implemented by the department and was agreed upon with the Licensee.

Upon a tour of the facility, LPA's found that cleaning supplies and other potentially harmful toxins and items were secured in designated laundry room. Staff were actively washing resident laundry during the time of visit and supervising the items. LPA's observed the facility postings on the kitchen bulletin, hallway and front door but did not observe documentation of the probationary stipulations visibly posted. LPA spoke with the Administrator who stated that the stipulation was not posted. Administrator located copy of the documented probation stipulation and posted it in the common space bulletin. Monthly training records as per stipulation have been completed and documented for 3 out of 3 caregiver staff implemented by the Administrator. All staff on duty were confirmed to be cleared and associated.

During the tour, LPA's observed 1 out of 3 restrooms showers not properly operating and 1 out of 3 restroom sink and shower drains in need of repair. Additionally, 2 out of 3 restroom flooring is in need of repairs as it presents a potential trip hazard due to broken or loose flooring.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Dominic Tobola
LICENSING PROGRAM ANALYST 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.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/24/2025 11:49 AM - It Cannot Be Edited


Created By: Dominic Tobola On 07/24/2025 at 11:03 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
07/24/2025
Section Cited
HSC
1569.38(e)

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1569.38 Posting of licensing reports; disclosure to new residents (e) ..the notice described in subdivision (b), the licensed residential care facility shall also post a written notice.. in a conspicuous location in the facility..
This was not met as evidence by:**
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Licensee and Administrator immediately placed the documented stipulation of probation in a conspicuous location of the facility. Deficiency cleared.
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Based upon LPA observation and interview with Licensee, it was found that the documented stipulation of probation was not posted in a conspicuous location in the facility. This serves as a potential personal rights risk to residents in care.
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Type B
07/31/2025
Section Cited
CCR87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This was not met as evidence by:**
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Licensee agrees to submit a written plan of how the repairs listed will be addressed. Plan to be submitted to CCL by POC date 7/31/2025. In addition, Licensee to submit LIC9098 Proof of Corrections form and receipt of repair services
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Upon LPA's observations, 1 out of 3 restrooms showers not properly operating and 1 out of 3 restroom sink and shower drains in need of repair. Additionally, 2 out of 3 restroom flooring is in need of repairs as it presents a potential trip hazard due to broke or loose flooring. This serves as a potential health & safety risk to residents in care.
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indicating all corrections/repairs have been completed by POC date 8/31/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Dominic Tobola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST 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


LIC809 (FAS) - (06/04)
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