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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601009
Report Date: 09/20/2024
Date Signed: 09/20/2024 12:01:13 PM


Document Has Been Signed on 09/20/2024 12:01 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 LLCFACILITY NUMBER:
415601009
ADMINISTRATOR:HU, CHUNJIEFACILITY TYPE:
740
ADDRESS:87 BERTA CIRTELEPHONE:
(650) 754-0234
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:7CENSUS: 5DATE:
09/20/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Hongyi Liang and May YuTIME COMPLETED:
12:20 PM
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On September 20, 2024, Licensing Program Analystss(LPAs) Komal Charitra and Kiran Jain conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citations that were issued on 09/18/2024 during an annual inspection. LPAs met with Caregivers, May Yu and Hongyi Liang, and explained the purpose of the visit. ShengXi Liu, Administrator joined shortly after.

On 09/18/2024, the facility was cited for California Code of Regulation (CCR), 87303(a) Maintenance and Operation, 87303(d) Maintenance and Operation, 87305(a) Alterations to Existing Building or New Facilities, 87307(a)(2)(B) Personal Accommodations and Services, 87307(d)(6) Personal Accommodations and Services, 87309(a) Storage Space, 87555(b)(8) General Food Service Requirements, 87412(g) Personnel Records, 87465(h)(2) Incidental Medical and Dental Care Services, 1569.695(c) Other Provisions,87506(a), 87705(j) Care of Persons with Dementia, 87506(a) Resident Records. Deficiencies, 87309(a), 87555(b)(8), 87465(h)(2) were all cleared and dismissed during the annual visit conducted on 9/18/2024.

During the visit, LPAs observed and cleared the following deficiencies; California Code of Regulations, Section, 87303(a) as LPAs observed bathroom in bedroom #4 was clean and dry, partially burnt power strip was replaced, mold in bedroom #3 was cleaned/fixed, 87303(d) as LPAs observed an additional lighting fixture was installed in bedroom #3, 87307(d)(6) as all indoor and outdoor passageways were observed to be clear and free from obstruction, 87705(j) as LPAs observed door alarm in bedroom #4 was observed to be in working condition, 87506(a) as resident records reviewed were updated and current.

No deficiencies cited during the visit. Report is reviewed with ShengXi Liu, Administrator, and a copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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