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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210012
Report Date: 12/14/2023
Date Signed: 12/14/2023 05:04:04 PM

Document Has Been Signed on 12/14/2023 05:04 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
SAN BRUNO RO, 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:
12/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Imelda Prado, Administrator/LicenseeTIME COMPLETED:
05:15 PM
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On December 14, 2023, Licensing Program Analysts(LPA) John Calandra and Licensing Program Manager(LPM) Jackie Jin arrived at the facility to conduct an unannounced to conduct the annual 1-year required inspection.

LPA and LPM toured the physical plant. The facility is one building with two floors. The Facility has 5 bedrooms and 2 bathrooms(4 resident bedrooms and 1 staff bedroom). No accessible bodies of water or hazards were observed. Water temperature in both the first and second floor bathrooms was measured at 107.9 degrees well within the required 105-120 required range. LPA Calandra and LPM Jin observed 7 days of non-perishables and 2 days of perishables. No food in the refrigerator has expired. All fire extinguishers were last serviced on January 19, 2023 and are fully charged.

All sharp objects, soap, and detergents were observed to be locked and in-accessible to persons in care.

LPA and LPM reviewed Medications Record and all resident medications which matched the instructions on the bubble pack of medication, the times of day medication should be taken were clearly noted as well as whether medications had been given to the resident.

LPA Calandra and LPM Jin interviewed 3 residents and 1 staff member.

This Annual will be completed at a later date.

No deficiencies were cited during today's visit. A copy of the report was reviewed with the Administrator and left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2023
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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