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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 11:28:13 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Shengxi "Simon" Liu, applicant/administratorTIME COMPLETED:
10:40 AM
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On 01/15/21 at 10:10AM, LPA Daisy Panlilio conducted a Component III tele-visit presentation with applicant/administrator. Due to COVID-19 shelter in place order, the applicant/administrator was not physically available to sign this report.

LPA discussed with applicant/administrator the most common deficiencies found in residential care facilities for the elderly and the corresponding Title 22 regulation sections.
The applicant was reminded of the statute that requires CCL to be notified within 5 business days of admitting their first resident. This notification can be done by mail, phone or by fax.

Exit interview conducted and a copy of this report provided to applicant/administrator via email.
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)
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