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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601009
Report Date: 12/20/2024
Date Signed: 12/20/2024 11:16:35 AM

Document Has Been Signed on 12/20/2024 11:16 AM - 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/
DIRECTOR:		HU, CHUNJIEFACILITY TYPE:
740
ADDRESS:87 BERTA CIRTELEPHONE:
(650) 754-0234
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 7TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/20/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Shengxi (Simon) LiuTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On December 20, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to complaint control #14-AS-20241216115839. LPA met with Administrator, Shengxi (Simon) Liu and explained the purpose of the visit.

During the complaint visit, it was indicated by the administrator that there were six residents at the facility, all which have dementia based on file reviewed. Administrator stated that he went to get groceries for the facility when Resident 1 (R1) eloped. At the time there was only one staff member (S1) providing care to the six residents with dementia. According to the administrator, S1 had to call the administrator to let him know that R1 eloped. Because there was no other staff member present, S1 was unable to leave all the residents to go find R1.

Nevertheless, due to the lack of staffing, R1 was able to elope from the facility twice on 12/11/24.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with the administrator, and a copy is provided with appeal rights.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305
DATE: 12/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/20/2024
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 12/20/2024 11:16 AM - 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: 12/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87411 Personnel Requirements - General:
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...

This requirement is not met as evidenced by:
Deficient Practice Statement
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POC Due Date: 12/21/2024
Plan of Correction
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Facility shall submit a new LIC500 and submit a plan to ensure staffing is sufficient throughout the day/night. Facility shall submit a plan on how to ensure residents needs are being met, including hiring additional staff if required
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305

DATE: 12/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2024

LIC809 (FAS) - (06/04)
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