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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201029
Report Date: 06/23/2022
Date Signed: 06/23/2022 03:39:47 PM


Document Has Been Signed on 06/23/2022 03:39 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
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: 7DATE:
06/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:48 PM
MET WITH:Shengxi Liu, AdministratorTIME COMPLETED:
03:54 PM
NARRATIVE
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On 10/13/2021 at 1:48 pm, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrators, Chunjie Hu and Shengxi Liu and explained the purpose of the visit.

LPA observed screening station that contained hand sanitizer, masks and COVID signage. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and backyard. LPA observed cough etiquette and physical distancing posted in the common areas. All hand washing stations were equipped with soap, paper towel, and hand washing posters.

During record review, LPA observed visitors log and temperature logs for residents or staff.

The following deficiencies were observed during the visit:

-At 2:14 pm, LPA observed unlocked garage door that contains pine sole, tide laundry soap, and other chemicals.
-At 2:15 pm, LPA observed a small room in the garage without a permit and is not on the facility sketch.
-At 2:16 pm LPA observed the side gate was locked.
-At 2:18 pm, LPA observed mattress, bedframe, 2 toilet seats, pipe, rat trap, wood panels, wire, rake, dolly, unlocked shed, wheel barrow, wood stacked up next to the shed.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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 06/23/2022 03:39 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by locking side gate which poses an immediate health and safety risk to persons in care.

POC Due Date: 06/24/2022
Plan of Correction
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Staff removed lock during inspection. Deficiency cleared during visit.

Civil penalty of $500 is being assessed.
Type A
Section Cited
CCR
87309(a)(1)
87309 Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by having the garage door unlocked and accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 06/24/2022
Plan of Correction
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 Administrator agreed to turn the door knob on the garage door around to lock from the outside in to the home and provide photos to CCLD no later then the CCLD no later then the POC date.

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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/23/2022 03:39 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Added room without permit 87305(a)
Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by adding a room without a permit which poses a potential health and safety risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Administrator will submit approved permit from the local county department along with a new facility sketch to CCL no later than the POC date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation 87303(a)

(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 requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having materials bedframe, mattress, 2 toilet seats, rat trap, wire, rake, wood panel, dolly, shovels building materials window, which poses a potential health and safety risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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Administrator will remove building materials bedframe, mattress, 2 toilet seats, rat trap, wire, rake, wood panel, dolly, shovels, window from the backyard and will provide pictures to CCL no later than the POC date.

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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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