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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601009
Report Date: 12/20/2024
Date Signed: 12/20/2024 11:15:18 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/16/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241216115839
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: 6DATE:
12/20/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Shengxi (Simon) Liu TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident left the facility unassisted
INVESTIGATION FINDINGS:
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On December 20, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Shengxi (Simon) Liu and explained the purpose of the visit.

Regarding the allegation, resident left the facility unassisted, according to the reporting party, on 12/11/2024, Resident 1 (R1), left the facility twice at 11am and 4pm. At 11am R1 was found in the neighborhood and at 4pm R1 was found in San Francisco.

During the visit, LPA interviewed the administrator and reviewed R1's file. According to the administrator, on 12/11/24, there was one staff member present when R1 left the facility at 11am because administrator went to get groceries. At 4pm, on the same day, there were two staff members present, however because they were helping other residents and despite having door alarms, R1 left the facility again and was found in San Francisco. According to R1's file, R1 has a diagnosis of dementia and is unable to leave the facility unassisted.

Therefore, the allegation resident left the facility unassisted is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with the administrator and a copy is provided with appeal rights. Copy of an immediate $500 civil penalty is provided due to absence of supervision.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20241216115839
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LLC
FACILITY NUMBER: 415601009
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2024
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by
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The Licensee/Administrator will develop a plan to ensure residents are being supervised at all times and to evaluate residents if they are elopement risks. Administrator/licensee will provide a copy of the plan to CCL by 12/21/24
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Based on file reviews and interviews, R1 has a diagnosis of dementia and is unable to leave the facility unassisted, however R1 left the facility two times on 12/11/24, at 11am and at 4pm. Although the facility doors have working alarms, R1 was still able to leave the facility with two staff members being present which poses an immediate health and safety risk to residents in care.
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Immediate Civil Penalty of $500.00 is being assessed today 12/20/24 for absence of supervision.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2