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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 12:01:59 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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, ShengXi LiuTIME COMPLETED:
12:20 PM
NARRATIVE
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On September 20, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra conducted an unannounced case management visit to follow up on a visit conducted on 9/18/2024. LPAs met with Administrator, ShengXi Liu, and Caregivers, May Yu and Hongyi Liang and explained the purpose of the visit.
During the visit, LPAs observed caregiver (S1) to not be fingerprint cleared at the facility. Based on interviews and file reviews, S1 was determined to not have fingerprint clearance. According to the administrator, S1 has been working at the facility for over a year and has been providing care and supervision to residents in care.

An civil penalty of $500 is assessed ($100 x 5 days) for Caregiver not being fingerprint cleared, however providing care and supervision to residents in care.

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 Administrator, ShengXi Liu and a copy is provided with appeal rights. A copy of the civil penalty is also provided to the administrator.
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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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 (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: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2024
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department or....

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator shall ensure S1 does not work and/or is present at the facility until S1 is fingerprint cleared or has an exemption
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Based on observations, LPAs observed S1 to providing care and supervision to clients in care however, based on record review, S1 was obseved to not have any fingerprint clearance. According to the administrator, S1 has been working at the facility for more than a year.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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