079201029-1-4-2024-15-AS-CFOR-CZ6UPC-20240104144520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079201029
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:45:47 PM

Document Has Been Signed on 01/04/2024 02:45 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 2		FACILITY NUMBER:	079201029
ADMINISTRATOR:	HU, CHUNJIE		FACILITY TYPE:	740
ADDRESS:	112 CHESTNUT DR		TELEPHONE:	(510) 281-0678
CITY:	HERCULES	STATE: CA	ZIP CODE:	94547
CAPACITY:	8	CENSUS: 4	DATE:	01/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Chunjie Hu, Administrator		TIME COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/04/2024 at 9:30AM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced 1-Year Required inspection. LPA met with Chunjie Hu, and explained the purpose of the visit. Shengxi Liu, Co-Administrator arrived at 10:20pm. The Administrator certificate has expired as of 5/4/2023 and is working on renewal process. The Co-Administrator currently holds a certificate (#6043972740) that expires on 04/27/2025. The facility’s fire clearance was approved for five (5) non-ambulatory and three (3) bedridden residents. LPA toured the facility with Administrators including but not limited to bedrooms, bathrooms, kitchen, common area, garage and backyard. The facility consists of six (6) total bedrooms, and two (2) bathrooms. No bodies of water observed. A comfortable temperature is maintained at 72 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. However the light bulbs in both bathrooms need to be replaced. The hot water temperature in the residents’ shared bathroom was measured at 114.7 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars. Smoke detectors and carbon monoxide were in operating condition during visit. Fire extinguisher was last serviced on 02/2/2022. Emergency Disaster Plan was last posted on 11/20/2023. First aid kit was observed to be complete. Facility did not have both Administrator and two (2) staff files including CPR/First Aid Certificates available. Four (4) residents files were reviewed were incomplete. Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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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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: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having sharps, eye drops, scrubbing bubbles, fish oil, laundry detergent, Lysol accessible to residents in care which poses an immediate health and safety risk to persons in care.
	POC Due Date: 01/05/2024
	Plan of Correction
1 2 3 4	Administrator removed chemicals and locked the sharps drawer. Deficiencies cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/04/2024 02:45 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: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having shovel, hedge cutters, saw, ladder, sledge hammer, paint, propane, and pick axe which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/23/2024
	Plan of Correction
1 2 3 4	Administrator agreed to put items in storage no later then the POC date and submit photos of correction to CCLD.

Type B

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above building two (2) rooms located in the backyard and one (1) room in the garage without obtaining a building permit which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/23/2024
	Plan of Correction
1 2 3 4	Administrator agreed to submit a form 200 and a new updated facility sketch to CCLD no later then 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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/04/2024 02:45 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: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above by not having proof of Administrator or staff with CPR/first aid on duty which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	Administrator agreed to read, understand regulation and provide CCLD with self certification no later then the POC date.

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
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above by not maintaining the Administrators and staff files at the facility which poses a potential health and safety risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	Administrator agreed to read, understand regulation and provide CCLD with self certification and a copy of all files required staff/residents no later then 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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(8)

General Food Service Requirements

(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having expired and freezer burned foods which poses a potential health and safety or risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	Administrator agred to get rid of expired and freezer burned food and replinish perishable and non-perishable food and send a photo to CCLD no later then the POC date.

Type B

Section Cited

CCR

87203

87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The fire extinguisher is missing the service tag, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/11/2024
	Plan of Correction
1 2 3 4	Administrator will ensure fire extinguisher is serviced and submit proof of serviced extinguisher tag to CCL by 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 Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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: 01/04/2024

NARRATIVE

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Continued from LIC809.

LPA observed the following deficiencies:

· At 9:45am, LPA observed unlocked drawer in the kitchen with knives and scissors.
· At 9:47am, LPA observed scrubbing bubbles disinfectant in unlocked cabinet underneath kitchen sink.
· At 9:50am, LPA observed facility did not have 7-day of non-perishable and 2-day of perishable foods available for residents. Facility had expired non-perishable and freezer burned perishable food.
· At 9:57am, LPA observed fish oil supplement and eye drops in an unlocked cabinet located in the kitchen.
· At 10:05am, LPA observed air freshener, laundry detergent, propane, Lysol, ladder, wheelchair and other items in unlocked garage obstructing the walkway.
· At 10:10am, LPA observed a room without a permit in the garage.
· At 10:15am, LPA observed a building with two (2) rooms in the process of being build in the backyard with a permit or contacting CCLD before starting project.
· At 10:18am, LPA observed hedge cutters, saw, ladder, sledge hammer, bleach, paint, shovel, pick ax and unlocked storage unit.

At 10:40am, LPA observed staff files missing from the facility and resident files incomplete.

Continued on LIC809C.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

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: 01/04/2024

NARRATIVE

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Continued from LIC809C.

LPA requested the following documents to be submitted to CCLD by 1/11/2024.

· Resident Roster
· LIC 308 Designation of Administrative Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan (9 pages)
· Liability Insurance

The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

*An immediate $1000.00 civil penalty will be assessed on today's date for associations.*

Exit interview conducted. A copy of the LIC421BG, this report and appeal rights provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024

LIC809 (FAS) - (06/04)

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