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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601009
Report Date: 10/27/2026
Date Signed: 10/27/2026 07:43:32 PM

Document Has Been Signed on 10/27/2026 07:43 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PRN CARE HOME LLCFACILITY NUMBER:
415601009
ADMINISTRATOR/
DIRECTOR:		HU, CHUNJIEFACILITY TYPE:
740
ADDRESS:87 BERTA CIRTELEPHONE:
(650) 754-0234
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 7CENSUS: 7DATE:
10/27/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:45 PM
MET WITH:HongYi Liang and Chunje HuTIME VISIT/
INSPECTION COMPLETED:
07:45 PM
NARRATIVE
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LPA Audrey Jeung conducted annual inspection; inspected building and grounds, seven-day emergency food supply, dishes, utensils, equipment necessary for the storage, preparation and service of food, linen supply, checked hot water temperature in main client bathroom at 111 degrees F. Carbon monoxide detector is tested and operable. There is no signal system installed, as all bedrooms are within close proximity.
This facility is one level, with 4 client bedrooms, 2 full bathrooms, kitchen, living/dining room, office area, and attached 1-car garage, where the washer and dryer are located. There is a twin bed in "staff room" in dining area. There is a fenced backyard, which is accessible only from room #4. Backyard is shared with adjacent home, which is where landlord/owner lives. There are 3 detached storage sheds, one of which is not accessible to facility staff, as it is used by landlord/owner.
There is locked cabinet for medications in the dining area. Toxic cleaning products are stored in garage.

Client records are reviewed today. Staff records and medications will be reviewed at a later date.

The following forms are accessible at www.CDSS.ca.gov and are to be completed and returned to CCL by 11/10/26:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 610 Emergency Disaster Plan (including signature and date on page 9)
• Proof of current liability insurance

Deficiencies of the CA Code of REgulations, Title 22 are observed and cited on a following page.
April Cowan
Audrey Jeung
DATE: 10/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2026
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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Document Has Been Signed on 10/27/2026 07:43 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/27/2026 at 06:15 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PRN CARE HOME LLC
FACILITY NUMBER: 415601009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/28/2026
Section Cited
CCR
87606(c)

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FIRE CLEARANCE
To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. This requirement is not met, as
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Plan/proof of correction to be sent to CCLD BY DUE DATE.
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client #4 is BEDRIDDEN per MD, but facility does not have approval for bedridden. Licensee failed to ensure appropriate fire clearance is granted for retention of bedridden client, which poses an immediate health or safety risk to clients in care.
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Type B
11/10/2026
Section Cited
CCR87307(c)

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PERSONAL ACCOMMODATIONS/SVCS
Individual privacy shall be provided in all toilet, bath and shower areas. This requirement is not met, as commode is used in all 3 shared bedrooms. Licensee failed to ensure that privacy is accorded when toileting, which poses a potential health,
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Plan/proof of correction to be sent to CCLD BY DUE DATE
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safety or personal rights risk to clients in care.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2026 07:43 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/27/2026 at 06:33 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PRN CARE HOME LLC
FACILITY NUMBER: 415601009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2026
Section Cited
CCR
87303(a)(1)

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MAINTENANCE AND OPERATION
The facility shall be clean, safe, sanitary and in good repair at all times.....surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
Main client bathroom has strong urine smell. Licensee failed to ensure that bathrooms is
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Bathrooms shall be maintained in clean, sanitary and odorless condition.
Plan/proof of corrction to be sent to CCLD BY DUE DATE.
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odorless, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
11/10/2026
Section Cited
CCR87608(a)(3)

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POSTURAL SUPPORTS
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record...
This requirement is not met, as 5 out of 7 clients have half bed rails and there are no MD orders maintained. Licensee failed to
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MD orders for Half bed rails for clients #1, #3, #4, #5, #6 will be sent to CCLD BY DUE DATE
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ensure that MD orders are maintained for residents who use half bed rails, which poses a potential health, safety or personal rights risk for clients in care.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2026 07:43 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/27/2026 at 06:49 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PRN CARE HOME LLC
FACILITY NUMBER: 415601009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2026
Section Cited
CCR
87307(a)(3)(B)

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PERSONAL ACCOMMODATNS/SVCS
Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident...licensee shall assure provision of...bedroom furniture, which shall include, for each resident, a chair, nightstand,
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Chairs shall be installed so each client has a chair in his/her bedroom.
Proof of correction to be sent to CCLD BY DUE DATE
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a lamp, or lights sufficient for reading, and a chest of drawers. This requirement is not met, as there are no chairs in 3 shared bedrooms. Licensee failed to ensure that required furnishings are installed for each client, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
10/28/2026
Section Cited
CCR87463(h)

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REAPPRAISALS
The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every 12 months...Documentation of the annual routine visit...shall be added to the resident's record.
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MD reports for clients #1, #2, #3, #5, #6 are dated more than 12 months ago and must be updated.
Civil penalty of $100/day will continue to accrue until plan/proof of correction is sent to CCLD. See LIC421FC
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This requirement is not met, as MD assessments for 5 out of 7 clients are dated more than 12 months ago. Licensee failed to ensure that annual MD assessments are documented. This is repeat violation within 12 months. Civil penalty of $250 is assessed.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2026 07:43 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/27/2026 at 07:06 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
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PRN CARE HOME LLC
FACILITY NUMBER: 415601009

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2026
Section Cited
CCR
87463(a)

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REAPPRAISALS
The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met, as
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Reappraisals for all clients except #2 shall be completed and signed.
Civil penalty of $100/day will continue to accrue until plan/proof of correction is sent to CCLD. See LIC 421 FC.
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appraisals for 6 out of 7 clients are dated more than 12 months ago or not complete or signed by responsible party. Licensee failed to ensure that appraisals are done annually. This is repeat violation within 12 months. Civil penalty of $250 is assessed.
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Type B
11/10/2026
Section Cited
CCR87468(b)(1)(A)

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PERSONAL RIGHTS
At the time the admission agreement is signed, a resident and the resident's representative shall be personally advised of and given a copy...licensee shall have each resident and the resident's representative sign a copy of these rights and the signed
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Personal Rights forms shall be signed by responsible parties of clients #3, #4, #5, #6, and include contact information of licensing agency.
Proof of correction to be sent to CCLD BY DUE DATE.
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copy shall be included in the resident's record. This requirement is not met, as Personal Rights forms are not signed by 4 out of 6 clients' responsible parties, which poses a potential health, safety or personal rights risk to clients in care.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2026


LIC809 (FAS) - (06/04)
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