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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600432
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:25:23 PM


Document Has Been Signed on 06/20/2023 04:25 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:
06/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:William EncarnacionTIME COMPLETED:
10:30 AM
NARRATIVE
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On 06/20/23, Licensing Program Analyst (LPA) Grace Donato and Komal Charitra conducted an unannounced Case Management visit in reference to complaint number 14-AS-20230420142536. LPAs met with Licensee/Administrator, William Encarnacion and explained the purpose of the visit.

During a complaint investigation, it was discovered that the PNI money for the residents are commingled with the other resident’s money and facility funds. Based on the records review, there is a monthly PNI log where it’s listed how much money was released to residents. For the logs, whenever the PNI money is spent by the administrator to buy items for the residents such as cigarettes, a receipt was not available to show proof of purchase.

However, when records for bank statements were reviewed, checks deposited is unclear if it’s the resident’s PNI money. These checks are combined with the facility’s fund so there is no clear indication to distinguish how much of it is the resident’s PNI money.

Deficiencies of the California Code of Regulations, Title, 22, are cited today on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with administrator. A copy of this report and the Appeal Rights is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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Document Has Been Signed on 06/20/2023 04:25 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 385600432

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/21/2023
Section Cited
CCR
87217(b)

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87217 Safeguards for Resident Cash, Personal Property, and Valuables (b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff. The licensee shall give the residents receipts for all
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Licensee shall develop a plan in writing on how it will address the disbursement log issue. In writing to explain how the licensee will address obtaining receipts after purchasing items for residents.Licensee will submit plan to CCL by 06/21/23 EOD.
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such articles or cash resources.
This requirement is not met as evidenced by facility administrator did not ensure purchased items for residents had receipts showing proof of purchase which possess an immediate health, safety or personal rights risk to persons in care.
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Type A
06/21/2023
Section Cited
CCR87217(e)

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Safeguards for Resident Cash, Personal Property, and Valuables (e) Cash resources and valuables of residents which are handled by the licensee for safekeeping shall not be commingled with or used as the facility funds or petty cash, and shall be separate, intact and free from any liability the licensee incurs in the
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Licensee shall develop a plan in writing on how it will address the disbursement log issue. Licensee will submit plan to CCL by 06/21/23 EOD.
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use of his own or the facility's funds and valuables. This does not prohibit the licensee from providing advances or loans to residents from facility money.
This requirement is not met as evidenced by based on records review, licensee did not ensure PNI money are not commingled with the facility funds which possess an immediate health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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