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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201029
Report Date: 03/24/2026
Date Signed: 03/24/2026 06:35:17 PM

Document Has Been Signed on 03/24/2026 06:35 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/
DIRECTOR:		HU, CHUNJIEFACILITY TYPE:
740
ADDRESS:112 CHESTNUT DRTELEPHONE:
(510) 281-0678
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY: 8CENSUS: 5DATE:
03/24/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH:SHENGXI LIU, CO-ADMINISTRATORTIME VISIT/
INSPECTION COMPLETED:
07:00 PM
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On 3/24/2026 at 1:40PM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Shengxi Liu, and explained the purpose of the visit. The Co-Administrator certificate 7013388740 expires on 4/27/2027. The facility’s fire clearance was approved for five (5) non-ambulatory and three (3) bedridden residents.

LPA toured the facility with Co-Administrators including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ shared bathroom was measured at 111.0 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars.

Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher is not tagged. Emergency Disaster Plan was last posted on 03/24/2026. First aid kit was observed to be incomplete.

Facility did not have both Co-Administrator and one (1) staff files complete including CPR/First Aid Certificates available. Three (3) residents files were reviewed were complete.

CONTINUE ON LIC809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 03/24/2026
NARRATIVE
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continue from LIC 809C

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights provided
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
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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: 03/24/2026
NARRATIVE
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Continued from LIC809.

LPA requested the following documents to be submitted to CCLD by 4/1/2026.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

LPA observed the following deficiencies:
  • At 1:50pm, LPA observed the fire extinguisher has no tag or purchase receipt.
  • At 1:55pm, LPA observed unlocked sharps drawer.
  • At 2:00pm, LPA observed a building with two (2) rooms in the process of being build in the backyard with a permit or contacting CCLD before starting project.
  • At 2:10pm, LPA observed a generator, wood planks, large can of food, debris, cement, toilet, pipes, paint, rake, Lysol and a shovel, ladder.
  • At 2:20pm, LPA observed unlocked medications located in the kitchen.
  • At 2:25pm, LPA observed pre-poured medications located in a locked cabinet in the kitchen.
  • At 3:00pm, LPA observed staff files incomplete.



continue on LIC 809C
NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Carol Fowler
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 06:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/24/2026 at 05:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 unlocked knives, scissors, lysol in an unlocked drawer located in the kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/26/2026
Plan of Correction
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Administrator agreed to read and understand regulation, self-certify and conduct inservice training with staff and submit sign in sheet with attendies by the POC date. Administrator locked sharps during visit.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

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 medicaction 3 unknown pills, Pepto Bismol, and Calmoseptine cream located in the kitchen which poses an immediate health and safety risk to persons in care.
POC Due Date: 03/26/2026
Plan of Correction
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Administrator agreed to read and understand regulation, self-certify and conduct inservice training with staff and submit sign in sheet with attendies by 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 06:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/24/2026 at 05:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 prepoured medication which poses an immediate health and safety or personal rights risk to persons in care.
POC Due Date: 03/26/2026
Plan of Correction
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Administrator agreed to read, self-certify and conduct in-service training wiht staff submit the sign in sheet to the department by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 06:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/24/2026 at 05:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings 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 building a building located in the backyard without a permit which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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Administrator agreed to submit an LIC200 and an updated facility sketch to the department by the POC date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

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 debris, wood planks, rake, buckets, sink located on both sideyard and backyard which poses a potential health and safety risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Administrator agreed to have the debris, wood planks, rake, buckets sink located on the sideyard hauled away and submit photos to the department by 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/24/2026 06:35 PM - It Cannot Be Edited


Created By: Carol Fowler On 03/24/2026 at 05:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having the Co-Administrators file/records located at the facility which poses a potential health and safety or personal rights risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Administrator agreed to have a copy of the Co-Administrator and all staff files/records at the facility at all times. Administrator will read understand regulation and self-certify and submit certification to the department by the POC date.
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

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 not maintaining a complete first aid kit at the facility which poses a potential health and safety risk to persons in care.
POC Due Date: 04/08/2026
Plan of Correction
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Administrator agreed to read understand regulation self certify and submit a photo of a completed first aid kit to the department by 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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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Created By: Carol Fowler On 03/24/2026 at 05:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87203
87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by having a fire extinguisher without a service tag which poses a potential health and safety risk to persons in care.
POC Due Date: 04/01/2026
Plan of Correction
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2
3
4
Administrator agreed to service fire extinguisher or purchase a new one and submit a photo to the department by the POC date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Carol Fowler
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/24/2026


LIC809 (FAS) - (06/04)
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