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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601009
Report Date: 10/28/2025
Date Signed: 10/28/2025 01:48:14 PM

Document Has Been Signed on 10/28/2025 01:48 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/
DIRECTOR:		HU, CHUNJIEFACILITY TYPE:
740
ADDRESS:87 BERTA CIRTELEPHONE:
(650) 754-0234
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 7CENSUS: 6DATE:
10/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH: Shengxi (Simon) LiuTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On October 28, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspections. LPA met with Caregiver, Hongyi (Jack) Liang and explained the purpose of the visit. Administrator, Shengxi (Simon) Liu joined shortly thereafter.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are three resident rooms, all of which were observed to be shared rooms. Resident rooms were observed with all required furniture. LPA observed Resident 1 (R1's) bed to have a full bed rail. Administrator indicated R1 is not on hospice. Two full bathrooms were observed to be odor-free and in good repair. Water temperature throughout the facility measured between 127-131 degrees F. Extra linen was observed to be present.

Dining room was observed free from tripping hazards. A comfortable temperature of 71 degrees F is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. Extra food supply was observed to be present. Sharps and chemicals were observed to be locked and inaccessible to residents. LPA observed R1's prescribed insulin unlocked and accessible in the refrigerator.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and are observed charged. LPA reviewed 6 resident records and 4 staff records. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. 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
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Curley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2025
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
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 9
Document Has Been Signed on 10/28/2025 01:48 PM - It Cannot Be Edited


Created By: Komal Curley On 10/28/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(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
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Based on observations, LPA observed mice droppings in the garage where facility stores their non-perishables which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/administrator shall clean the mice droppings from the shelves and send LPA a photo. Licensee/administrator shall submit a plan in writing to ensure facility is free from pests. Plan should include hiring third party pest control services to treat the facility.
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed and interviews, 3/4 staff were observed to not have the required training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/administrator shall develop a plan in writing on how to ensure staff complete annual training. The plan shall include conducting audits and ensuring all training is logged and maintained in each staff file.
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 Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 10/28/2025 01:48 PM - It Cannot Be Edited


Created By: Komal Curley On 10/28/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 4/4 staff records reviewed, 4/4 staff did not have their first aid/CPR training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/administrator to enroll all staff in first aid/CPR training and provide LPA confirmation of enrollment and the date of enrollment. Once completed, Licensee/administrator shall submit LPA a copy and ensure cards are maintained in each staff file.
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
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Based on observations, LPA observed R1's prescribed insulin unlocked and accessible in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/administrator shall lock R1's insulin and provide LPA a photo of medication being locked and inaccessible.
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 Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/28/2025 01:48 PM - It Cannot Be Edited


Created By: Komal Curley On 10/28/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 4/6 resident records reviewed, LPA did not observe any documentation to show that 4/6 of the residents have received an annual routine visit with a licensed professiona oncel every year which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/administrator shall schedule annual routine appointments with a licensed medical professional for the 4 residents. Licensee/administrator shall ensure documentation of the appointment is maintained in the resident's files.
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed R1's bed to have a full bed rail. Based on interviews and records reviewed, R1 is not on hospice which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2025
Plan of Correction
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Licensee/administrator shall remove the full bed rail from R1's bed and provide LPA a photo.
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 Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 10/28/2025 01:48 PM - It Cannot Be Edited


Created By: Komal Curley On 10/28/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, the water temperature throughout the facility measured between 127-131 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2025
Plan of Correction
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Licensee/administrator shall adjust the water heater and ensure water temperature is between 105-120 degrees F. Licensee/administrator to submit LPA video/photo of water temperature being within regulatory requirements.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, Administrator was unable to provide a complete file for Staff 1 (S1) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2025
Plan of Correction
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Licensee/administrator shall ensure S1's file is complete and signed and maintained at the facility. Licensee/administrator shall submit a copy of S1's file to LPA by 11/4/25.
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 Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 10/28/2025 01:48 PM - It Cannot Be Edited


Created By: Komal Curley On 10/28/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)
Resident Records
(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 6/6 resident records reviewed, the files were not complete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2025
Plan of Correction
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Licensee/administrator shall audit all resident files and ensure all required documents under CCR87506 are signed and completed and maintained in each resident's file.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on 6/6 resident records reviewed, 3/6 resident files did not have a pre-admission appraisal in their files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2025
Plan of Correction
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Licensee/administrator shall complete pre-admission appraisals for the 3 residents and ensure it is maintained in the residents files.
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 Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 10/28/2025 01:48 PM - It Cannot Be Edited


Created By: Komal Curley On 10/28/2025 at 12:27 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/28/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on 6/6 resident record, 5/6 resident records did not have a service plan and/or had an outdated service plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2025
Plan of Correction
1
2
3
4
Licensee/administrator shall complete service plan/reappraisals for all residents to ensure it's being updated once every 12 months.
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 records reviewed and interview, Administrator was unable to provide LPA documenation to show that emergency drills are being conducted at least quarterly which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/04/2025
Plan of Correction
1
2
3
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Licensee/administrator shall begin documenting emergency drills quarterly and maintain a log at the facility. Licensee/administrator shall conduct an emergency drill by 11/4/25 and provide LPA a sign in sheet.
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 Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2025


LIC809 (FAS) - (06/04)
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