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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200828
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:08:43 PM

Document Has Been Signed on 02/19/2025 04:08 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:RICHARDS MANOR IIFACILITY NUMBER:
435200828
ADMINISTRATOR/
DIRECTOR:		RICHARDS, SHIRLEYFACILITY TYPE:
735
ADDRESS:4242 MONET CIRCLETELEPHONE:
(408) 622-8067
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 3DATE:
02/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Shirley RichardsTIME VISIT/
INSPECTION COMPLETED:
02:08 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management visit and met with Administrator (ADM) Shirley Richards.

The purpose of this visit is to follow up with the case management conducted on 02/04/2025.

On 01/16/2025, at 9:12AM, resident R1 attacked resident R2 with scissors. R2 obtained laceration on the right side of the face and bleeding in the middle head skull. R2 was sent to hospital. R1 was apprehended and booked into jail.

Based on the interview with staff, there was a altercation among R1 and R2 before R1 attacked R2 with scissor.

Based on the review of law enforcement task forces report, R1 and R2 got into argument and R1 grabbed scissors to attack R2. The incident is an assault with a deadly weapon and criminal threats.

The facility staff did not take action after the alteration between R1 and R2, and were lack of supervision on residents leading in R1 attacked R2 with scissors. R2 obtained laceration on the right side of the face and bleeding on R1's head. R2 was sent to hospital emergency room.

Citation noted for today's visit. See LIC809-D.

Exit interview was conducted with ADM. The report was provided to ADM for review and signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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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Document Has Been Signed on 02/19/2025 04:08 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 02/17/2025 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: RICHARDS MANOR II
FACILITY NUMBER: 435200828

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/20/2025
Section Cited
CCR
80078(a)

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80078 Responsibility for Providing Care and Supervision, (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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Administrator stated to send a plan of correction by the POC due date to ensure residents to receive the necessary care and supervision, and provide the staff training on how to provide care and supervision. Administrator stated to send the staff training log to CCL office.
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Based on interview and record reviewed, the facility staff lack of supervision resulting in resident R1 attacked R2 with scissors, and R2 obtained severe injuries which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type A
02/20/2025
Section Cited
CCR80087(g)

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80087 Buildings and Grounds (g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement was not met as evidenced by:
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Administrator stated to send plan of correction by the POC due date to ensure weapons including scissors are kept inaccessible to residents.
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Based on interview and record reviewed, resident R1 attacked resident R2 with a deadly weapon scissors, and R2 obtained severe injuries which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:
DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025


LIC809 (FAS) - (06/04)
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