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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201029
Report Date: 01/27/2025
Date Signed: 01/27/2025 06:04:14 PM

Document Has Been Signed on 01/27/2025 06:04 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: 8TOTAL ENROLLED CHILDREN: 0CENSUS: 3DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:10 PM
MET WITH:Shengxi Liu, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:20 PM
NARRATIVE
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On 1/27/2025 at 1:10PM, 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 expires on 4/27/2025. 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 114.5 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 8/29/2019. First aid kit was observed to be complete.

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.

Continued on LIC809C.
Bennett FongTELEPHONE: (510) -62-2621
Carol FowlerTELEPHONE: (510) 622-2715
DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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 9
Document Has Been Signed on 01/27/2025 06:04 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/27/2025 at 04:02 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: 01/27/2025

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 knife, meat clever and scissors unlocked in a kitchen drawer which poses an immediate health and safety risk to persons in care.
POC Due Date: 01/28/2025
Plan of Correction
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Administrator locked knives and scissors during visit. DEFICIENCY CLEARED DURING VISIT.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Bennett Fong
TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME:Carol Fowler
TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/27/2025 06:04 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/27/2025 at 04:02 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
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 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 bathroom #1 sink dirty and floor needs to be swept. Bathroom #2 shower floor needs repair which poses a potential health and safety risk to persons in care.
POC Due Date: 01/31/2025
Plan of Correction
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Co-Administrator agreed to clean the bathroom and repair bathroom # 2 shower floor and submit photos by the POC date.
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 building two (2) rooms located in the backyard and one (1) room in the garage without obtaining a building permit which poses a potential health and safety risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator agreed to provide a permit or submit a form 200 and updated facility sketch 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.
SUPERVISOR'S NAME:Bennett Fong
TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME:Carol Fowler
TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 01/27/2025 06:04 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/27/2025 at 04:02 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

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 having two staff without CPR/First Aid training working and Administrator out of town which poses a potential health and safety risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Co-Administrator agreed to get CPR/First Aid training for him and staff working submit photo copies to the Department by the POC date.
Type B
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

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 expired food in the refrigerator with an odor which poses a potential health and safety or personal rights risk to persons in care.
POC Due Date: 01/30/2025
Plan of Correction
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Administrator agreed to clear all expired foods from the refrigerator 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.
SUPERVISOR'S NAME:Bennett Fong
TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME:Carol Fowler
TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 01/27/2025 06:04 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/27/2025 at 04:02 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

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 kitchen are not clean and a glue trap with incest on it which poses a potential health and safety risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator agreed to clean the kitchen and submit photos to the Department by the POC date
Type B
Section Cited
CCR
1569.625(B)(2)
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 not having documents for annual training which poses a potential health and safety risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator has agreed to obtain training documents for staff's annual training and submit a copy to CCLD by 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 Fong
TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME:Carol Fowler
TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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Document Has Been Signed on 01/27/2025 06:04 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/27/2025 at 04:43 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87212(c)
87212 Emergency Disaster Plan

(c) Emergency exiting plans and telephone numbers shall be posted. This requirement was not met as evidenced by:


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 a current Emergency and Disaster Plan which poses a potential health and safety risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator agreed to update post and submit a copy of Emergency and Disaster Plan (610E) to the Department by the POC date.
Type B
Section Cited
CCR
87203
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
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Based on observation, the fire extinguishers did not have any inspection tags or purchase receipt taped on cylinder to show date of purchase or when last inspected which posed a potential Health & Safety risk to residents in care.
POC Due Date: 01/30/2025
Plan of Correction
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Administrator agreed to have fire extinguisher serviced or purchase a new extinguisher and provide a copy of the purchase receipt or service tag 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.
SUPERVISOR'S NAME:Bennett Fong
TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME:Carol Fowler
TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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Document Has Been Signed on 01/27/2025 06:04 PM - It Cannot Be Edited


Created By: Carol Fowler On 01/27/2025 at 04:52 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(4)
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

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 dust pan, portable bed, pipes, wood, table, mixer, chairs, walker, paint, Lysol, boxes, water cooler, Ortho groundclear, boxes of cement, open can of food, hoses, toilet, cement blocks, shovel, large tree branch and ladder located in the back yard which poses a potential health and safety risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator agreed to remove all items and put them in storage to be inaccessible to residents in care and submit photos to the department by the POC date.
Type B
Section Cited
CCR
87412(a)
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review of four staff files, the licensee did not comply with the section cited above in having incomplete employee files for 3 of 3 employees records reviewed which poses a potential health and safety risk to persons in care.
POC Due Date: 02/10/2025
Plan of Correction
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Administrator agrees to read the regulation review and update all employee files and provide a checklist and a sample of all required documents for each file to the Department by 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 Fong
TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME:Carol Fowler
TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


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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: 01/27/2025
NARRATIVE
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continue from LIC 809C

· At 2:20pm, 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 2:26pm, LPA observed a room without a permit in the garage.
· At 2:29pm, LPA observed a large dead tree in the back yard.
· At 2:35pm, LPA observed a generator, wood planks, large can of food, debris, cement, toilet, pipes, paint, rake, Lysol and a shovel, ladder.
  • At 3:40am, LPA observed staff files incomplete.

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.

*An immediate $100.00 civil penalty will be assessed on today's date for associations.*

Exit interview conducted. A copy of the LIC421BG, 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: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
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Page: 8 of 9
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: 01/27/2025
NARRATIVE
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Continued from LIC809C.

LPA requested the following documents to be submitted to CCLD by 2/10/2025.

· 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 1:45pm, LPA observed the fire extinguisher has no tag or purchase receipt.
· At 1:47pm, LPA observed no Emergency and Disaster Plan updated and posted.
· At 1:50pm, LPA observed bathroom #1 sink and floor needs to be cleaned.
· At 1:53pm, LPA observed bathroom #2 shower floor is in disrepair.
· At 1:59pm, LPA observed kitchen sink has dishes and needs to be cleaned.
· At 2:10pm, LPA observed unlocked sharps drawer.
· At 2:12pm, LPA observed the freezer and both refrigerators has odor and needs cleaning.
· At 2:18pm, LPA observed expired can foods, ladder, laundry soap, propane and other chemicals unlocked in the garage.

continue on LIC 809C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
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