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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201029
Report Date: 02/02/2023
Date Signed: 02/02/2023 01:38:16 PM


Document Has Been Signed on 02/02/2023 01:38 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:PRN CARE HOME 2FACILITY NUMBER:
079201029
ADMINISTRATOR:HU, CHUNJIEFACILITY TYPE:
740
ADDRESS:112 CHESTNUT DRTELEPHONE:
(510) 281-0678
CITY:HERCULESSTATE: CAZIP CODE:
94547
CAPACITY:8CENSUS: 5DATE:
02/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Chunjie Hu, AdministratorTIME COMPLETED:
01:50 PM
NARRATIVE
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On 2/2/2023 at 11:05AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct an Infection Control Inspection. LPA met with Administrator, Chunjie Hu and explained the purpose of the visit.

Upon entry, LPA temperature was checked. LPA observed screening station and COVID-19 signs posted near screening station. LPA toured facility including but not limited to common areas, bathrooms, bedrooms, kitchen, garage and back yard. All hand washing stations were equipped with soap and paper towel. Hand washing posters were posted at hand washing stations. There is a minimum of 7-days non-perishables and 2-day perishables foods.
During record review, LPA observed facility has a copy of the mitigation plan on file. LPA observed food and paper supplies are sufficient.

The following deficiencies were observed:
  • At 10:17AM LPA observed residents with half bed rails without doctors orders.
  • At 10:18AM LPA observed chemicals in 1st and 2nd bathroom such as lysol, scrubbing bubbles, glade and febreez air fresheners.
  • At 10:20AM LPA observed kitchen cabinet unlocked which contains knives.
  • At 10:22AM LPAs observed fire extinguisher expired 1/20/2021.
  • At 10:25AM LPA observed unlocked garage door which contained kirkland laundry detergent, fabuloso, fabric softener.
  • At 10:27AM LPA observed a room that's not on the facility sketch.


Continued on LIC808C
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029
VISIT DATE: 02/02/2023
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Continue on LIC9099
  • At 10:30AM LPA observed bed frames, shovel, toilet top, wood shelves, mirror, Weed B Gone, chairs, window and unlocked shed.



The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. A copy of this report and appeal rights provided

The following forms are to be updated and submitted to CCLD 2/9/2023:

-LIC500 Personnel Report

-LIC308 Designation of Administrative Responsibility

-LIC610E Emergency Disaster Plan

-An updated copy of Administrator certificate

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 02/02/2023 01:38 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203(a)
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having the fire extinguisher serviced, and locking the front door with a prohibited lock which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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Administrator will remove the prohibited lock on the front door and provide CCLD with photos no later than POC date.
Administrator will service or purchase a new fire extinguisher no later than the POC date and provide CCLD with photos.

Civil penalty of $500 is being assessed.
Type A
Section Cited
CCR
87705(f)(1)(2)(3)
87705 Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
(3) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator had over the counter medication and cleaning supplies such as scrubbing bubbles, fabuloso, laundry detergent, febreez over the counter medications fish oil, CoQ10, vitamins, and lysol in a unlocked garage. Administrator also had an unlocked drawer with knives accessible to residents which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/03/2023
Plan of Correction
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Administrator will read and understand the regulation and conduct an in-service training with staff and provide CCLD with a signed list of attendees no later than the POC 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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 02/02/2023 01:38 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612


FACILITY NAME: PRN CARE HOME 2
FACILITY NUMBER: 079201029

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Added room without permit 87305(a)

Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.
This requirement is not met as evidenced by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation licensee did not comply with the section cited above by making alterations to the garage by adding a room which poses a potential health and safety risk to residents in care.
POC Due Date: 02/16/2023
Plan of Correction
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Administrator will submit a LIC200 along with a new facility sketch to CCL no later than the POC date.

Civil penalty of $500 is being assessed.
Type B
Section Cited
CCR
87303(a)
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 was not met as evidence by:


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation licensee did not comply with the section cited above by having, shovel, bed frames, dolly, toilet top, wood shelves, mirror, Weed B Gone, chairs, window and other items located in the backyard which poses a potential health and safety risk to residents
POC Due Date: 03/02/2023
Plan of Correction
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Administrator agreed remove all items shovel, bed frames, dolly, toilet top, wood shelves, mirror, Weed B Gone, chairs, window from the backyard and provide photos to CCLD no later than the POC date.

Repeat Civil penalty of $500 is being assessed.

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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4