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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210012
Report Date: 02/15/2023
Date Signed: 02/15/2023 06:34:31 PM

Document Has Been Signed on 02/15/2023 06:34 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RANDALL HOMEFACILITY NUMBER:
419210012
ADMINISTRATOR:IMELDA PRADOFACILITY TYPE:
735
ADDRESS:4 RANDALL COURTTELEPHONE:
(650) 755-5084
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
02/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Imelda PradoTIME COMPLETED:
10:45 AM
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On 2/15/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted and screened by the administrator, Imeda Prado. LPA explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies. There are 6 residents at the facility and 2 present during the inspection; the other residents are either at adult day program or medical appointment. There are 2 private rooms and 2 shared rooms with beds observed to be 6" apart. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash cans are observed to have foot operated close lids.

The facility appeared to be cleaned and tidy. Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

During today's inspection, LPA Han obtained a copy of administrator certification, LIC610D, and LIC500.

No deficiency cited today.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2023
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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