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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601009
Report Date: 03/09/2022
Date Signed: 03/09/2022 09:51:27 AM


Document Has Been Signed on 03/09/2022 09:51 AM - 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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PRN CARE HOME LLCFACILITY NUMBER:
415601009
ADMINISTRATOR:HU, CHUNJIEFACILITY TYPE:
740
ADDRESS:87 BERTA CIRTELEPHONE:
(650) 754-0234
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:7CENSUS: 4DATE:
03/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Albert LiuTIME COMPLETED:
10:15 AM
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On March 9, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on the annual visit from October 21, 2021. LPA met with Caregiver, Albert Liu and explained the purpose of the visit. LPA was screened at entry point.

LPA toured the facility and observed 3 residents and 2 caregivers, including Albert during the visit. LPA Charitra observed 4 resident rooms and 2 bathrooms. LPA observed a closet room in front of the kitchen. LPA advised the caregivers that the closet should not be used as a personal accommodation for staff or residents. In addition, LPA Charitra indicated that no room commonly used for other purposes shall be used as a sleeping room for any
resident or staff.

No citations were issued at this time.

Report reviewed with Caregiver, Albert Liu and a copy will be provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/09/2022
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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