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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210012
Report Date: 12/15/2023
Date Signed: 12/15/2023 10:23:13 AM

Document Has Been Signed on 12/15/2023 10:23 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
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:
12/15/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Imelda Prado, Administrator/LicenseeTIME COMPLETED:
10:30 AM
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On December 15, 2023, Licensing Program Analysts(LPAs) John Calandra and Grace Donato, conducted an unannounced continuation of the Annual 1-year required inspection that was started on December 14, 2023. LPAs Calandra and Donato met with Administrator, Imelda Prado.

LPA Calandra and Donato reviewed 5 residents and 2 staff files. All were observed to be complete.

No deficiencies were cited during today's visit. A copy of this report was reviewed and provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2023
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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