<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200828
Report Date: 09/07/2021
Date Signed: 09/08/2021 08:11:17 AM

Document Has Been Signed on 09/08/2021 08:11 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
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:RICHARDS MANOR IIFACILITY NUMBER:
435200828
ADMINISTRATOR:RICHARDS, SHIRLEYFACILITY TYPE:
735
ADDRESS:4242 MONET CIRCLETELEPHONE:
(408) 622-8067
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 5DATE:
09/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Shirley Richards, ADMTIME COMPLETED:
10:00 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Steve Chang and Program Clinical Consultant (PCC) Helen Shi conducted Technical Assistant PCC through tele-inspection, and met with Administrator (ADM) Shirley Richards.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During visit, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance to include screening questionnaire forms, hand sanitizer, face masks, glove, and a visitor log book.

The facility common areas were inspected such as the kitchen, living room, dinning room, bathrooms were observed. There are 6 resident bedrooms, 1 staff live-in bedroom, and 2 and half bathrooms in facility.

Facility bathrooms signage on hand washing, hand sanitizer, paper towel were observed, and trash cans with covers were observed. The laundry room was observed and inspected. ADM stated the dining area only allows two people to stay at one time. ADM stated the positive resident (R1) is isolating at R1's family home, and R1 will stay at R1's family home at least one more week. ADM stated all the residents have the single room.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: RICHARDS MANOR II
FACILITY NUMBER: 435200828
VISIT DATE: 09/07/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on today's inspection, the facility is being recommended the following:

1. If possible, all the visitors call the facility first to make an appointment.

2. ADM to post the complete list of COVID symptoms at the screening station.

3. ADM to have an extra thermometer at screening station.

4. ADM to remove cloth towel in kitchen, and to put paper towel with holder in kitchen.

5. ADM to put paper towel with holder in bathrooms.

6. ADM to put trash cans with foot pedal in bathrooms and kitchen.

7. ADM to put the procedures of doffing and donning of PPEs at the common area and at
the PPE stocking area.

8. ADM to put hand sanitizer and disinfects in the laundry area.

9. ADM to ensure the paper towel is not wet.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to the facility for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2