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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601009
Report Date:
09/18/2024
Date Signed:
09/18/2024 01:54:58 PM
Document Has Been Signed on
09/18/2024 01:54 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
SAN BRUNO RO
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
PRN CARE HOME LLC
FACILITY NUMBER:
415601009
ADMINISTRATOR:
HU, CHUNJIE
FACILITY TYPE:
740
ADDRESS:
87 BERTA CIR
TELEPHONE:
(650) 754-0234
CITY:
DALY CITY
STATE:
CA
ZIP CODE:
94015
CAPACITY:
7
CENSUS:
5
DATE:
09/18/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:10 AM
MET WITH:
May Yu, Caregiver
TIME COMPLETED:
02:30 PM
NARRATIVE
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On September 18, 2024, Licensing Program Analysts (LPA) Kiran Jain and Komal Charitra conducted an unannounced annual inspection. LPAs met with Caregivers, May Yu and Hongyi Liang and explained the purpose of the visit. ShengXi Liu, Administartor joined shortly after.
LPAs toured the facility inside and outside including but not limited to; all of resident rooms, common areas, garage, and bathrooms. No accessible bodies of water or fire safety hazards were observed. LPAs observed 4 resident rooms; 3 of which are shared rooms and 1 private resident room. Auditory alarm on the exit door in Bedroom #4 was observed to not be working. LPAs observed a partially burnt power-strip in bedroom #4. LPAs toured bedroom #2, medication was observed to be on the table next to resident's bed. LPAs toured bedroom #3 and observed mold on the ceiling and a small light fixture that doesn't provide sufficient lighting. Bathroom observed in the main hallway was observed to have chemicals on the floor. Bathroom located in Bedroom #4 was observed to have water on the floor and the faucet observed to be in disrepair. Water temperature throughout the facility measured at 116.2 degrees F.
Exit route from bedroom #4 going outside to the patio area in the backyard was observed to be shared with the home next door. The exit route was not clear from obstruction. LPAs observed suitcases, furniture, etc blocking passageway. LPA toured kitchen and observed two day perishable and seven day non-perishables. Fridge was observed to have open containers of food and expired milk. Sharps, chemicals, and medications were observed to be unlocked and accessible to residents.
Living room and dining area were observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. Carbon monoxide monitor was working properly. LPAs observed a closet in the living room, right across from the kitchen to have a bed and personal belongings.
LPAs toured the garage and observed washer and dryer to be in good repair. An extra refrigerator was observed with expired milk located in the freezer. During the tour of the garage, LPAs observed an office room in the garage that was observed to be constructed. LPAs observed a monitor, desk, chair and files.
(Continue to 809C).
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
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
9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION 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
VISIT DATE:
09/18/2024
NARRATIVE
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Garage was observed to be cluttered and passageway was blocked. Emergency drill logs were not provided to LPAs. According to staff interviewed, there has been no drills conducted since he/she was hired.
LPA reviewed 5 resident records. 2/5 resident files were not completed and updated. The other 3 files reviewed were updated, complete and signed. Personnel records were not present at the facility and facility staff were unable to provide personnel files to review. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.
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.
Report is reviewed with ShengXi Liu, Administartor and a copy is provided with appeal rights.
SUPERVISOR'S NAME:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
09/18/2024 01:54 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
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:
09/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the licensee constructed an office room in the garage which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/Administrator shall submit a plan in writing on how to address this deficiency by the POC due date.
Type A
Section Cited
CCR
87307(a)(2)(B)
Personal Accommodations and Services
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage, storage area, shed or similar detached building.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, LPAs observed a closet room right across from the garage, located next the dining room table to have a bed and personal belongings which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/Administrator indicated that he will remove beds and perosnal belongings from the closet by the POC due date.
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
09/18/2024 01:54 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
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:
09/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, the garage passageway was observed to be blocked with clutter. In addition, LPAs observed the exit route area from Bedroom #4 to the patio in the backyard to have suitcases, covered furniture, wheelchair and a desk chair blocking the exit route passeway which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/Administrator shall remove all items blocking the passeway in the garage and the backyard patio to ensure it is not a fire safety hazard and provide LPAs the photo of the correction by the POC due date.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, LPAs observed chemicals, and sharps unlocked and accessible to residents in the kitchen and in the bathroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/Administrator shall ensure locks on kitchen cabinets are repaired and provide LPA photos of locked chemicals and sharps. Licensee/Administrator shall provide staff training regarding the importance of locking sharps and chemicals.
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
09/18/2024 01:54 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
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:
09/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, no personnel records were present at the facility for review which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/Adminstrator shall ensure personnel records are complete and ensure it is maintained at the facility at all times.
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, LPAs observed a gallon of expired milk in the refrigerator. In addition, LPAs observed frozen milk in the garage freezer to also be expired which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Facility staff immediately threw away the expired milk. Deficiency is cleared and corrected.
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
09/18/2024 01:54 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
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:
09/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, LPAs observed medication cabinet to be unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Medication cabinet was immediately locked in LPAs presence. Deficiency cleared and corrected.
Type A
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, Bedroom #4 bathroom was observed to have water on the floor, faucet was observed to be in disrepair, power strip locatedi n bedroom #4 was observed partially burnt. In addition, LPAs observed Bedroom #3 with mold on the ceiling which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/administrator shall submit a plan in writing to indicate how to fix/address the issues mentioned above by 9/19/2024.
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
LIC809
(FAS) - (06/04)
Page:
6
of
9
Document Has Been Signed on
09/18/2024 01:54 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
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:
09/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(d)
Maintenance and Operation
(d) There shall be lamps or light appropriate for the use of each room and sufficient to ensure the comfort and safety of all persons in the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, LPAs toured bedroom #3 and observed a table light that does not provide sufficienct lighting for resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/administrator shall purchase new lighting fixture for resident and provide LPA with a copy of the receipt to show fixture has been bought. In addition, provide LPAs photos that fixture is installed.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interviews, no emergency drill log was provided and/or available to LPAs during the visit. Based on interviews, staff indicated she/he has not heard of any drills being conducted at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/Administrator shall conduct an emergency drill and provide a copy of the drill log to LPA.
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
LIC809
(FAS) - (06/04)
Page:
7
of
9
Document Has Been Signed on
09/18/2024 01:54 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
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:
09/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, Bedroom #4 has a resident with dementia. Bedroom #4 has an exit door leading from the room to the patio area in the backyard. The door alarm was observed to not be in working condition which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
09/19/2024
Plan of Correction
1
2
3
4
Licensee/administrator shall fix the door alarm and send LPAs a video/photo to ensure door alarm is in good working condition.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
LIC809
(FAS) - (06/04)
Page:
8
of
9
Document Has Been Signed on
09/18/2024 01:54 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
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:
09/18/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on 5 resident records reviewed, 1/5 resident does not have a file at all and 1/5 resident record does not have physician's report, needs and service plan, ermegency contact sheet which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/25/2024
Plan of Correction
1
2
3
4
Licensee/Administrator shall complete and maintain updated resident records at the facility.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
April Cowan
TELEPHONE:
(650) 266-8889
LICENSING EVALUATOR NAME:
Kiran Jain
TELEPHONE:
650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE:
09/18/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
09/18/2024
LIC809
(FAS) - (06/04)
Page:
9
of
9