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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601009
Report Date: 10/21/2021
Date Signed: 10/21/2021 12:11:20 PM

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: DATE:
10/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Albert LiuTIME COMPLETED:
12:15 PM
NARRATIVE
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On October 21, 2021, Licensing Program Analyst (LPA) Komal Charitra and Licensing Program Manager (LPM) Julio Montes, conducted an unannounced annual inspection. LPA and LPM observed COVID-19 signs posted by the entrance. LPA and LPM were greeted by Albert Liu (S1). LPA and LPM explained the purpose of the visit. LPA and LPM's temperature was checked at the front entrance, however, S1 did not ask screening questions.

LPA toured facility grounds. No accessible bodies of water. The house consists of a central area with the dining area and living room area. There is access to the kitchen and the garage. To the left of the front door are 3 bedrooms and 2 bathrooms, and to the right from the entrance there is another bedroom. The floor plan appears to differ to the original plan of 2017. It is noted that a new facility floor plan was received by CCLD on September 3, 2019, showing that the staff bedroom had been converted to a residents' room, and a new structure built in front of the kitchen and converted to caregiver's room. The most recent fire clearance is dated May of 2017. A new fire clearance will be needed. Kitchen area is covered with plastic and has a locking device on the door.

The bedrooms were observed and the beds in the semi-private rooms are 6 feet apart. Bathrooms were equipped with liquid hand soap. LPA advised S1 to get rid of bar soaps, have paper-towels instead of hand towels, and to cover trash cans with lids.

Medications are locked and inaccessible to residents, however the keys are accessible to anyone. A comfortable temperature is maintained, lighting is sufficient for comfort.

Infection control practices are not reviewed: entry procedures, COVID-19 signage, and 30-Day supply of PPE.

According to S1, all residents are vaccinated and one is on Hospice. Two residents are in the hospital.

LPA requests for the following documents be submitted by 10/28/2021:
-LIC500
-A copy of Administrator Certificate

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed with S1 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: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 415601009
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by: facility failed to ask screening questions; failed to post COVID-19 signage throughout the facility; failed to maintain a 30-Day PPE supply; failed to have paper-towels in the bathroom; failed to have trash cans with bins.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. Facility failed to ask screening questions upon arrival to the facility, keep an appropriate amount PPE, have COVID signage posted throughout the facility, and have bathrooms equipped with paper-towels.
POC Due Date: 10/28/2021
Plan of Correction
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The administrator/licensee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening for residents and staff members, masking guidance, COVID-19 protocol signage, and maintaining an adequate amount of PPE supply.
Type B
Section Cited
CCR
87412(a)


This requirement is not met as evidenced by: Albert Liu, staff member, is not listed on the LIC500 or the LIC555.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. According to Licensing records, Albert Liu is not associated with the facility or has received background clearance.
POC Due Date: 10/25/2021
Plan of Correction
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This is a Type A definiciency.

Facility will associate staff member with the facility immediately.
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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3