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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600874
Report Date: 04/21/2021
Date Signed: 08/01/2023 11:53:43 AM


Document Has Been Signed on 08/01/2023 11:53 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:BROOKDALE REDWOOD CITYFACILITY NUMBER:
415600874
ADMINISTRATOR:NDOMO, GRACEFACILITY TYPE:
740
ADDRESS:485 WOODSIDE RDTELEPHONE:
(650) 366-3900
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:130CENSUS: 70DATE:
04/21/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Executive Director, Grace NdomoTIME COMPLETED:
04:50 PM
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On 4/21/2021 Licensed Program Analysis (LPA) Han conducted an unannounced Case Management -COVID-19 inspection. The facility did not report an incident to the Regional Office in a timely manner.

Due to the Pandemic this inspection was conducted remotely.

LPA Han called and spoke to the Executive Director, Grace Ndomo and explained the purpose of the call. The Executive Director stated that this incident happened while she was on vacation and the facility took actions internally but due to some miscommunication, it was not reported to the Regional Office on time. The Executive Director will educate the managers on the Reporting Requirements.

This report was reviewed and discussed with the Executive Director. This report will be emailed to the Executive Director for a signature then returned to the LPA within twenty-four hours.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2021
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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