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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601009
Report Date: 03/02/2023
Date Signed: 03/02/2023 12:23:23 PM


Document Has Been Signed on 03/02/2023 12:23 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
SF COASTAL AC/SC, 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: 3DATE:
03/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hong Yi Liang (Jack)TIME COMPLETED:
12:30 PM
NARRATIVE
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During complaint investigation, LPA Jeung observed deficiency of the California Code of REgulations, Title 22. Deficiency cited on a following page.

The following medications are not maintained:

Client #1--Hydrocort 10 mg

Client #2--Lopid (Gemfibrozil) 600 mg

Client #3--Acetaminophen 500 mg, Docusate Sodium 250 mg, Haldol 1 mg, Cough & Chest Congestion D, Sarna Sensitive Anti-Itch, Senna 8.5 mg
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
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 2


Document Has Been Signed on 03/02/2023 12:23 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
SF COASTAL AC/SC, 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: 03/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/09/2023
Section Cited

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INCIDENTAL MEDICAL CARE
Prescription medications which are... otherwise to be disposed of shall be destroyed in the facility by the facility administrator & one other adult who is not a resident. Both shall sign a record, to be retained for at least 3 years, which lists...:
Name of the resident, Rx number, name of pharmacy, drug name, strength, quantity
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Plan of correction to be submitted to CCLD BY DUE DATE This shall include explanation of whereabouts for 6 medications for client #3, and 1 medication each for clients #1 and #2.
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destroyed, date of destruction.
This requirement is not met, as medications included on 3 clients' Medication Administration Records were stopped or discarded, per staff, but there is no documentation maintained of the MD orders or destruction. Licensee failed to ensure that records are maintained for med destruction, which poses a potential risk.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2