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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 06/02/2023
Date Signed: 06/02/2023 12:29:13 PM


Document Has Been Signed on 06/02/2023 12:29 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:
06/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Licensee/Administrator, William Encarnacion TIME COMPLETED:
12:40 PM
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On 6/2/23, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Case Management visit to deliver amended reports that was provided on May 16, 2023 by LPA Komal Charitra in reference to complaint number 14-AS-20230106144444. LPA met with Licensee/Administrator, William Encarnacion and explained the purpose of the visit.

The following reports were amended: LIC9099C, LIC9099D that were provided on May 16, 2023. In addition, LIC809 and LIC809D were amended from May 16, 2023. During the visit LPA amended the reports and provided Licensee with a copy.

This report is reviewed and discussed with Licensee and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2023
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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