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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601009
Report Date: 03/02/2023
Date Signed: 03/02/2023 12:28:15 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
02/22/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230222144033
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
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hong Yi Liang (Jack) and Sheng Xi Liu (Simon)TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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- Staff does not adequately maintin resident's medication records
- Staff does not provide adequate food service


INVESTIGATION FINDINGS:
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LPA Jeung met with staff, observed clients--one at dining table and 2 in their bedrooms--inspected food supply, and reviewed client files, including medications. LPA observed clients' medications--2 clients get medications from 1 pharmacy.

Based on information observed during this visit, these allegations are substantiated. The preponderance of evidence standard has been met.
Facility does not maintain Centrally Stored Medication Records, which are required. LPA observed that Medication Administration Records are maintained, which are not required.
Two day supply of fresh vegetables is not maintained. Half a head of napa cabbage is observed in refrigerator as well as 2-day supply of fresh protein and fruit, 7 day supplies of canned fruit, vegetables and protein.

Deficiencies of the California Code of REgulations, Title 22, are cited on a following page.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 14-AS-20230222144033
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
CCR
87465(h)(6)
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INCIDENTAL MEDICAL CARE
A record of centrally stored prescription medications for each resident shall be maintained & include names of the resident for whom prescribed, prescribing physician and pharmacist, drug name, strength, & quantity, dates filled, started & expiration, prescription number and instructions.
This requirement is not met, as evidenced
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Centrally Stored Medications Records for all clients will be completed and maintained. Copies of CSMRs to be sent to CCLD BY DUE Date with plan of correction.
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by review of client records and absence of Centrally Stored Medications Records. Licensee failed to ensure that CSMR is maintained to track clients' medications, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
03/09/2023
Section Cited
CCR
87555(b)(26)
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FOOD SERVICE
Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met, as facility does not maintain at least a 2 day supply of fresh vegetables. Licensee failed to ensure that
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Facility shall at all times maintain at least 2-day supply of fresh fruit, vegetables and protein.
REceipt for 2- day supply of fresh vegetables to be sent to CCLD BY DUE DATE.
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at least 2-day supply of fresh food is maintained, 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.
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
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
SF COASTAL AC/SC, 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
02/22/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230222144033

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
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Hong Yi Liang (Jack)TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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- Staff does not provide resident's food menu
INVESTIGATION FINDINGS:
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Facility does not maintain a written menu, per staff.

This allegation is determined to be unfounded,as this is not a requirement of Title 22 RCFE regulations. .
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 3