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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 04/28/2023
Date Signed: 04/28/2023 12:57:23 PM


Document Has Been Signed on 04/28/2023 12:57 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PSALM RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600432
ADMINISTRATOR:ENCARNACION, WILLIAM, SFACILITY TYPE:
740
ADDRESS:565 GROVE STTELEPHONE:
(415) 621-8505
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:22CENSUS: 16DATE:
04/28/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:William EncarnacionTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Grace Donato and Licensing Program Manager (LPM) Jackie Jin conducted an unannounced complaint investigation. LPA & LPM met with Caregiver, Jay Tacra and explained the purpose of the visit. Administrator, William Encarnacion, joined shortly thereafter.

During complaint investigation it was observed while touring the facility that an open space at the back of the facility has a bunk bed and cabinets that was occupied by two residents. Based on the facility sketch submitted to the Department, the back area is allotted for an open space. Administrator stated that the fire department approved that open space to occupy two residents.

LPA & LPM requested that administrator to submit an LIC 200 and a copy of the current facility sketch to CCLD by 05/03/2023. The Department will request a fire clearance to be cleared to allow residents to stay in the area.

No defiency cited during today's visit.

This report was reviewed with William Encarnacion and copy has been provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
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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