PRN Care Home

Type of visit: Required - 1 Year

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 rightsthe state’s words, verbatim · CDSS document, Oct 28, 2025

The state marks this report as 9 pages; the online copy we transcribed has 8. You can request the full file from the county licensing office.

Allegation investigated: Staff neglected to provide medical attention resulting into a stage 2 pressure injury

On 5/12/2025 LPA Grace Donato made an unannounced complaint investigation visit to deliver findings. LPA met with Care Staff Jack Liang and explained the purpose of the visit. Regarding the allegation, staff neglected to provide medical attention resulting into a stage 2 pressure injury, according to the reporting party, Resident 1 (R1) was observed to have a stage 2 pressure ulcer on his/her left heel that was still developing. LPA Charitra obtained the latest reappraisal of the resident dated 1/1/2025. There are no observations documenting a wound or stage 1 or 2 pressure injury. LPA Donato requested documentation of home health agreement from facility as proof that the stage 2 pressure ulcer was being addressed. After phone calls and emails, the facility was not able to present any written agreement. Based on records review, the allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and copy is provided with appeal rights. Substantiatedthe state’s words, verbatim · CDSS document, May 12, 2025 · control 14-AS-20250226164710

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b) · Plan of correction due date: May 13, 2025

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This was not met as evidenced by Licensee does not have an updated Needs and Appraisal form to document a significant change in condition of R1 having Stage 2 Pressure ulcer.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Licensee to submit a plan on how it will address the documentation of significant changes in of a resident in the facility. Licensee to submit my POC deadline, 5/13/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87609(b)(4) · Plan of correction due date: May 13, 2025

87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4)The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). This was not met as evidenced by Licensee was not able to provide a written agreement with a Home Health agency to address R1’s condition.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Licensee to submit a plan to ensure Home Health agreements are in place for residents needing the services. Licensee to also show proof of training for staff regarding Stage 1 and 2 pressure injuries. Licensee to submit my POC deadline, 5/13/2025.

Allegation investigated: Staff neglected to provide medical attention resulting into a stage 2 pressure injury

On 5/12/2025 LPA Grace Donato made an unannounced complaint investigation visit to deliver findings. LPA met with Care Staff Jack Liang and explained the purpose of the visit. Regarding the allegation, staff neglected to provide medical attention resulting into a stage 2 pressure injury, according to the reporting party, Resident 1 (R1) was observed to have a stage 2 pressure ulcer on his/her left heel that was still developing. LPA Charitra obtained the latest reappraisal of the resident dated 1/1/2025. There are no observations documenting a wound or stage 1 or 2 pressure injury. LPA Donato requested documentation of home health agreement from facility as proof that the stage 2 pressure ulcer was being addressed. After phone calls and emails, the facility was not able to present any written agreement. Based on records review, the allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and copy is provided with appeal rights. Substantiatedthe state’s words, verbatim · CDSS document, May 12, 2025 · control 14-AS-20250226164710

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b) · Plan of correction due date: May 13, 2025

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This was not met as evidenced by Licensee does not have an updated Needs and Appraisal form to document a significant change in condition of R1 having Stage 2 Pressure ulcer.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Licensee to submit a plan on how it will address the documentation of significant changes in of a resident in the facility. Licensee to submit my POC deadline, 5/13/2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87609(b)(4) · Plan of correction due date: May 13, 2025

87609 Allowable Health Conditions and the Use of Home Health Agencies (b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4)The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s). This was not met as evidenced by Licensee was not able to provide a written agreement with a Home Health agency to address R1’s condition.the state’s words, verbatim · CDSS document, May 12, 2025

Plan of correction: Licensee to submit a plan to ensure Home Health agreements are in place for residents needing the services. Licensee to also show proof of training for staff regarding Stage 1 and 2 pressure injuries. Licensee to submit my POC deadline, 5/13/2025.

Allegation investigated: Resident left the facility unassisted

On December 20, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Shengxi (Simon) Liu and explained the purpose of the visit. Regarding the allegation, resident left the facility unassisted, according to the reporting party, on 12/11/2024, Resident 1 (R1), left the facility twice at 11am and 4pm. At 11am R1 was found in the neighborhood and at 4pm R1 was found in San Francisco. During the visit, LPA interviewed the administrator and reviewed R1's file. According to the administrator, on 12/11/24, there was one staff member present when R1 left the facility at 11am because administrator went to get groceries. At 4pm, on the same day, there were two staff members present, however because they were helping other residents and despite having door alarms, R1 left the facility again and was found in San Francisco. According to R1's file, R1 has a diagnosis of dementia and is unable to leave the facility unassisted. Therefore, the allegation resident left the facility unassisted is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with the administrator and a copy is provided with appeal rights. Copy of an immediate $500 civil penalty is provided due to absence of supervision. Substantiatedthe state’s words, verbatim · CDSS document, Dec 20, 2024 · control 14-AS-20241216115839

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Dec 21, 2024

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by Based on file reviews and interviews, R1 has a diagnosis of dementia and is unable to leave the facility unassisted, however R1 left the facility two times on 12/11/24, at 11am and at 4pm. Although the facility doors have working alarms, R1 was still able to leave the facility with two staff members being present which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: The Licensee/Administrator will develop a plan to ensure residents are being supervised at all times and to evaluate residents if they are elopement risks. Administrator/licensee will provide a copy of the plan to CCL by 12/21/24 Immediate Civil Penalty of $500.00 is being assessed today 12/20/24 for absence of supervision.

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Dec 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Dec 21, 2024

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: Based on interviews and file reviews, on 12/11/24, there were six residents at the facility, all which have dementia. According to the administrator, he went to get groceries for the facility when R1 eloped and S1 was the only one present providing care to all six residents. Nevertheless, due to the lack of staffing, R1 was able to elope from the facility twice on 12/11/24 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Dec 20, 2024

Plan of correction: 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

Type of visit: POC

On September 20, 2024, Licensing Program Analystss(LPAs) Komal Charitra and Kiran Jain conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citations that were issued on 09/18/2024 during an annual inspection. LPAs met with Caregivers, May Yu and Hongyi Liang, and explained the purpose of the visit. ShengXi Liu, Administrator joined shortly after. On 09/18/2024, the facility was cited for California Code of Regulation (CCR), 87303(a) Maintenance and Operation, 87303(d) Maintenance and Operation, 87305(a) Alterations to Existing Building or New Facilities, 87307(a)(2)(B) Personal Accommodations and Services, 87307(d)(6) Personal Accommodations and Services, 87309(a) Storage Space, 87555(b)(8) General Food Service Requirements, 87412(g) Personnel Records, 87465(h)(2) Incidental Medical and Dental Care Services, 1569.695(c) Other Provisions,87506(a), 87705(j) Care of Persons with Dementia, 87506(a) Resident Records. Deficiencies, 87309(a), 87555(b)(8), 87465(h)(2) were all cleared and dismissed during the annual visit conducted on 9/18/2024. During the visit, LPAs observed and cleared the following deficiencies; California Code of Regulations, Section, 87303(a) as LPAs observed bathroom in bedroom #4 was clean and dry, partially burnt power strip was replaced, mold in bedroom #3 was cleaned/fixed, 87303(d) as LPAs observed an additional lighting fixture was installed in bedroom #3, 87307(d)(6) as all indoor and outdoor passageways were observed to be clear and free from obstruction, 87705(j) as LPAs observed door alarm in bedroom #4 was observed to be in working condition, 87506(a) as resident records reviewed were updated and current. No deficiencies cited during the visit. Report is reviewed with ShengXi Liu, Administrator, and a copy is provided.the state’s words, verbatim · CDSS document, Sep 20, 2024

Type of visit: Case Management - Deficiencies

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.the state’s words, verbatim · CDSS document, Sep 20, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Sep 21, 2024

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: 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.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Licensee/Administrator shall ensure S1 does not work and/or is present at the facility until S1 is fingerprint cleared or has an exemption

Type of visit: Required - 1 Year

On September 18, 2024, Licensing Program Analysts (LPA) Kiran Jain and Komal Charitra conducted an unannounced annual inspection. LPAs met with Caregivers, May Yu and Hongyi Liang and explained the purpose of the visit. ShengXi Liu, Administartor joined shortly after. LPAs toured the facility inside and outside including but not limited to; all of resident rooms, common areas, garage, and bathrooms. No accessible bodies of water or fire safety hazards were observed. LPAs observed 4 resident rooms; 3 of which are shared rooms and 1 private resident room. Auditory alarm on the exit door in Bedroom #4 was observed to not be working. LPAs observed a partially burnt power-strip in bedroom #4. LPAs toured bedroom #2, medication was observed to be on the table next to resident's bed. LPAs toured bedroom #3 and observed mold on the ceiling and a small light fixture that doesn't provide sufficient lighting. Bathroom observed in the main hallway was observed to have chemicals on the floor. Bathroom located in Bedroom #4 was observed to have water on the floor and the faucet observed to be in disrepair. Water temperature throughout the facility measured at 116.2 degrees F. Exit route from bedroom #4 going outside to the patio area in the backyard was observed to be shared with the home next door. The exit route was not clear from obstruction. LPAs observed suitcases, furniture, etc blocking passageway. LPA toured kitchen and observed two day perishable and seven day non-perishables. Fridge was observed to have open containers of food and expired milk. Sharps, chemicals, and medications were observed to be unlocked and accessible to residents. Living room and dining area were observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. Carbon monoxide monitor was working properly. LPAs observed a closet in the living room, right across from the kitchen to have a bed and personal belongings. LPAs toured the garage and observed washer and dryer to be in good repair. An extra refrigerator was observed with expired milk located in the freezer. During the tour of the garage, LPAs observed an office room in the garage that was observed to be constructed. LPAs observed a monitor, desk, chair and files. (Continue to 809C). Garage was observed to be cluttered and passageway was blocked. Emergency drill logs were not provided to LPAs. According to staff interviewed, there has been no drills conducted since he/she was hired. LPA reviewed 5 resident records. 2/5 resident files were not completed and updated. The other 3 files reviewed were updated, complete and signed. Personnel records were not present at the facility and facility staff were unable to provide personnel files to review. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated. 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 ShengXi Liu, Administartor and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Sep 18, 2024