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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600432
Report Date: 06/20/2023
Date Signed: 06/20/2023 11:55:04 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/20/2023 and conducted by Evaluator Grace Donato
COMPLAINT CONTROL NUMBER: 14-AS-20230420142536
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
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff is mishandling the residents personal funds while in care
INVESTIGATION FINDINGS:
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On 06/20/23, Licensing Program Analyst (LPA) Grace Donato and Komal Charitra met with administrator, William Encarnacion to deliver the findings for the above allegation.

It was reported that residents are not able to receive their monthly personal needs and incidental money (PNI).

Based on the interview with the administrator, the residents have access and are provided their PNI money when they ask for it. Any amount provided to the residents are logged in on a sheet of paper and signed by the resident. The logs were reviewed and stated the amount given to residents. Out of the 6 residents that were interviewed, everyone stated that they do get their PNI money when they ask for it. Whenever the residents request the administrator to buy items like cigarette cartons or medicines, the administrator provides the items requested to be bought.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20230420142536
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/20/2023
NARRATIVE
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Although the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

This report was discussed, reviewed and a copy is provided to William Encarnacion, Administrator.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2