<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601009
Report Date: 05/12/2025
Date Signed: 05/12/2025 09:48:34 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
02/26/2025 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250226164710
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:
05/12/2025
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Jack LiangTIME COMPLETED:
10:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglected to provide medical attention resulting into a stage 2 pressure injury
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 5/12/2025 LPA Grace Donato made an unannounced complaint investigation visit to deliver findings. LPA met with Care Staff Jack Liang and explained the purpose of the visit.

Regarding the allegation, staff neglected to provide medical attention resulting into a stage 2 pressure injury, according to the reporting party, Resident 1 (R1) was observed to have a stage 2 pressure ulcer on his/her left heel that was still developing.

LPA Charitra obtained the latest reappraisal of the resident dated 1/1/2025. There are no observations documenting a wound or stage 1 or 2 pressure injury. LPA Donato requested documentation of home health agreement from facility as proof that the stage 2 pressure ulcer was being addressed. After phone calls and emails, the facility was not able to present any written agreement.

Based on records review, the allegation 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 and copy is provided with appeal rights.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
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 3
Control Number 14-AS-20250226164710
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: 05/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2025
Section Cited
CCR
87463(b)
1
2
3
4
5
6
7
87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident.
1
2
3
4
5
6
7
Licensee to submit a plan on how it will address the documentation of significant changes in of a resident in the facility. Licensee to submit my POC deadline, 5/13/2025.
8
9
10
11
12
13
14
This was not met as evidenced by Licensee does not have an updated Needs and Appraisal form to document a significant change in condition of R1 having Stage 2 Pressure ulcer.
8
9
10
11
12
13
14
Type A
05/13/2025
Section Cited
CCR
87609(b)(4)
1
2
3
4
5
6
7
87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4)The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).
1
2
3
4
5
6
7
Licensee to submit a plan to ensure Home Health agreements are in place for residents needing the services. Licensee to also show proof of training for staff regarding Stage 1 and 2 pressure injuries. Licensee to submit my POC deadline, 5/13/2025.
8
9
10
11
12
13
14
This was not met as evidenced by Licensee was not able to provide a written agreement with a Home Health agency to address R1’s condition.
8
9
10
11
12
13
14
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: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
02/26/2025 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250226164710

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:
05/12/2025
UNANNOUNCEDTIME BEGAN:
08:59 AM
MET WITH:Jack LiangTIME COMPLETED:
10:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure resident received quality daily diet
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Regarding the allegation, facility staff did not ensure resident received quality daily diet, according to the reporting party, Resident 1 (R1) was observed to have poor oral consumption of food and fluid intake.

During the investigation, LPA reviewed the facility's food menu, R1's file and interviewed the staff and administrator. According to R1's physician's report dated 5/2023, R1 has a special mechanical soft diet. LPA reviewed the facility's food menu and observed that the facility does provide three meals a day with snacks in between each meal. LPA interviewed the staff and administrator who indicated, residents are served regular food, but the thing is before R1 left he/she wasn’t eating so R1 was provided Ensure. R1 is given what everyone else is eating, all soft because elderly and can barely eat.

Based on interviews and records review, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3