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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200828
Report Date: 05/18/2023
Date Signed: 05/21/2023 02:09:52 PM

Document Has Been Signed on 05/21/2023 02:09 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
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: 6DATE:
05/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Shirley RichardsTIME COMPLETED:
04:37 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection visit, and met with Administrator (ADM) Shirley Richards.

LPA checked 5 resident record files (R1 - R5) and 3 staff record files (S1 - S3). 2 residents (R1 - R2) and 2 staff (S2 - S3) were interviewed.

LPA toured the facility inside out with ADM. COVID posters were observed in the facility. Facility license, Personal Right posters were observed in the facility. Living room, family room, kitchen, dinning room and three restrooms were inspected. Paper towel were observed with holders. Cloth towels were observed in the kitchen and restrooms. Six single resident bedrooms, and laundry room were inspected. Two staff live-in rooms were observed in facility. Two day perishable food supplies and seven day nonperishable food supplies were observed sufficient. Medication closet, knives closet, and cleaning product closet were observed locked. But one knife was observed left at the kitchen sink. Room temperature was at 70 degree F, and hot water temperature was at 109 degree F in facility.

Fire extinguisher was serviced on 4/18/2023. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors and carbon monoxide detectors were tested by ADM, and were found no batteries. ADM changed the batteries immediately. Front yard and backyard were inspected. There was no obstruction to block the walkways.

Deficiencies were found today. LIC809-D were attached. Appeal Rights were attached. Exit interview was conducted with ADM. This report was provided to ADM for signature. A copy of the report was provided to ADM.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 05/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/18/2023
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 4
Document Has Been Signed on 05/21/2023 02:09 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/18/2023 at 04:30 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: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, smoke and carbon monoxide detectorsdid not have batteries, the the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Administrator changed the batteries immediately.
POC Due Date: 05/19/2023
Plan of Correction
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Administrator agrees to submit the plan of correction by the POC due date.
Type A
Section Cited
CCR
80087(g)
Building 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 is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, a kinve was observed at the kitchen sink, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Administrator has a locked knive closet, Administrator put the knive in the locked closet immediately.
POC Due Date: 05/19/2023
Plan of Correction
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Administrator agreed to submit a plan of correction by the POC due date.
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: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/21/2023 02:09 PM - It Cannot Be Edited


Created By: Chihhsien Chang On 05/18/2023 at 04:30 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: 05/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80019(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, more than one staff did not associate with the facility, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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Administrator agreed to submit the plan of correction by the POC due date.
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, two resident files did not have adminission agreement, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2023
Plan of Correction
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Administrator agreed to submit plan of correction by POC due date.
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: 05/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/18/2023


LIC809 (FAS) - (06/04)
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