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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 06/15/2023
Date Signed: 06/15/2023 02:59:52 PM


Document Has Been Signed on 06/15/2023 02:59 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: DATE:
06/15/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Licensee/Administrator, William Encarnacion TIME COMPLETED:
03:00 PM
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
On June 15, 2023 San Bruno Regional Office conducted a non-compliance conference meeting with Licensee/Administrator, William Encarnacion.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Managers, Cara Smith and Jackie Jin, and Licensing Program Analysts, Komal Charitra and Murial Han. Also present in the meeting was Local Long Term Care Ombudsman, Benson Nadell and Luis Calderon from San Francisco Department of Public Health.

During non-compliance meeting, the following violations were discussed: Basic Services, Reporting Requirements, Maintenance and Operation, Personal Accommodations, Incidental, Medical, and Dental Care, Criminal Record Clearance, Reappraisal, Personal Rights of Residents in All Facilities, Administrator Qualifications and Duties, Accountability of Licensee Governing Body, and Observation of the Resident.

In addition, during the non-compliance meeting, Regional Manager, Vivien Helbling hand delivered a copy of an immediate exclusion letter to exclude an employee of the facility who was involved with the incident of financial abuse. Licensee was informed that appeal that was made on 5/22/23 will be denied and a copy of denied appeal response will be mailed.

During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring inspection visits to ensure compliance with this compliance plan of Title 22 regulation. Licensee was provided the link below for resources and guidance to improve facility operations:
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers

The Licensee was informed that additional civil penalties for serious violations that resulting for serious bodily injuries may be assessed, pending review. Report is reviewed with the Administrator 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: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/15/2023
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 1