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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600432
Report Date: 08/26/2026
Date Signed: 08/26/2026 02:51:07 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
07/30/2026 and conducted by Evaluator Yi Sam Jian
COMPLAINT CONTROL NUMBER: 14-AS-20260730124500
FACILITY NAME:PSALM RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600432
ADMINISTRATOR:ANNA VILLANUEVA-AOAYFACILITY TYPE:
740
ADDRESS:565 GROVE STTELEPHONE:
(415) 621-8505
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:22CENSUS: 14DATE:
08/26/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anna AoayTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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-Facility refrigerator is in disrepair.
INVESTIGATION FINDINGS:
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On 08/26/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with administrator, Anna Aoay, LPA explained the purpose of the visit.
Regarding the allegation that facility refrigerator is in disrepair, the Department conducted investigation, the LPA's direct observation of the nonfunctioning refrigerator, combined with information from the interview conducted and documentation reviewed, establish that the facility failed to maintain the refrigerator in proper working condition.
The Department determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
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 3
Control Number 14-AS-20260730124500
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 08/26/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This was not met as evidence by:
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Facility received funding from outside sources and replaced the malfunctioning kitchen refrigerator with a functioning refrigerator per LPA observation on 08/26/2026.
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Upon LPA's observations, refrigerating compartment of the kitchen refrigerator was not functioning and in need of repair. This serves as a potential health & safety risk to residents 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: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
07/30/2026 and conducted by Evaluator Yi Sam Jian
COMPLAINT CONTROL NUMBER: 14-AS-20260730124500

FACILITY NAME:PSALM RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600432
ADMINISTRATOR:ANNA VILLANUEVA-AOAYFACILITY TYPE:
740
ADDRESS:565 GROVE STTELEPHONE:
(415) 621-8505
CITY:SAN FRANCISCOSTATE:CAZIP CODE:
94102
CAPACITY:22CENSUS: 14DATE:
08/26/2026
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Anna AoayTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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9
-Unqualified staff providing supervision and care.
-Uncleared adult allowed to work in the facility.
INVESTIGATION FINDINGS:
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On 08/26/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with administrator, Anna Aoay, LPA explained the purpose of the visit.
Regarding the allegation that an unqualified staff member was providing supervision and care, LPA received conflicting statements during interviews and did not obtain sufficient corroborating evidence to establish that an unqualified staff member provided supervision or care to residents.
Regarding the allegation that an uncleared adult allowed to work in the facility, LPA received conflicting statements during interviews and did not obtain sufficient corroborating evidence to establish that an Uncleared adult allowed to work in the facility.
Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3