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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201029
Report Date: 01/15/2021
Date Signed: 01/15/2021 11:24:40 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:PRN CARE HOME 2FACILITY NUMBER:
079201029
ADMINISTRATOR:HU, CHUNJIEFACILITY TYPE:
740
ADDRESS:112 CHESTNUT DRTELEPHONE:
(510) 281-0678
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:8CENSUS: 0DATE:
01/15/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shengxi "Simon" Liu, Applicant/AdministratorTIME COMPLETED:
10:00 AM
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On 01/15/21 at 9AM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an announced pre-licensing tele- visit with applicant/administrator. Due to COVID-19 shelter in place order, applicant/administrator was not physically available to sign this report.

LPA toured the facility inside and outside including but not limited to resident's bedrooms, bathrooms, dining room, common living areas, kitchen, and outside patios. There is sufficient lighting around the facility. Resident's rooms were equipped with the proper furniture and lighting. Resident's rooms had proper bedding and linens for the residents. Bathrooms were equipped with grab bars and hygiene items. Living room is equipped with the proper furniture for the residents. All toxins and sharp objects were locked inside the kitchen drawer. Passageways and hallways were free of obstruction. Fire extinguisher was observed fully charged. Smoke detectors were observed hard wired in the bedrooms, kitchen and living room areas. Medication cabinet was locked and first aid kit was complete. All exit doors in the facility are equipped auditory signals. LPA observed the facility had the necessary posters in place (COVID-19 signs, visitor policy, Personal rights, rights to council, etc). There was a locked area for medications in the hallway closet adjacent to the entry way. The garage contained locked cabinets for storing toxins, detergents, cleaning supplies, gardening supplies, and tools. Beds were made with appropriate linens and additional linens were observed to be on hand in the closet. Furniture and lighting were observed to be safe and adequate. Each bedroom was furnished with a bed, bedding, a night stand, a chair, and sufficient closet space. Hot water temperature in the resident bathrooms tested at 110 degrees Fahrenheit. There were no bodies of water present at the facility. Outside pathways to security exit gate were unobstructed.

(Continued on Page 2)
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029
VISIT DATE: 01/15/2021
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As this is a new facility, no residents were present during today’s visit. LPA verified there is a lan line telephone in the facility, which is currently operating. During today's visit, LPA reviewed LIC 610E Emergency disaster plan/Fire and Earthquake drill requirements. Due to COVID-19 shelter in place, applicant/administrator was not physically available to sign this report.

No deficiencies were observed during the pre-licensing inspection. LPA observed the facility is ready to be licensed. However, this report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed and is subject to final approval by CAU.

Additional requirements may still be required.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Rajind BasiTELEPHONE: (510) 286-4201
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2021
LIC809 (FAS) - (06/04)
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