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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200828
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:24:08 PM

Document Has Been Signed on 07/09/2024 04:24 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/
DIRECTOR:
RICHARDS, SHIRLEYFACILITY TYPE:
735
ADDRESS:4242 MONET CIRCLETELEPHONE:
(408) 622-8067
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 4DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Shirley RichardsTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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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 2 resident record files and 2 staff record files. 2 residents and 3 staff were observed in the facility.

LPA toured the facility inside out with ADM. Facility license, Personal Right posters, and Administrator Certificate were observed in the facility. Living room, family room, kitchen, dinning room and three restrooms were inspected. Six 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. Room temperature was at 70 degree F, and hot water temperature was at 109 degree F in facility. Non skid mats were observed in the bathrooms. The temperature of the refrigerator was at 35 degree F, and the temperature of the freezer was at 0 degree F.

Fire extinguisher was serviced on 4/24/2024. The facility was equipped with fire alarm system, smoke and carbon monoxide detectors. Smoke detectors and carbon monoxide detector was tested by ADM, and was working fine. First aid box, flash lights and night lights were observed in the facility. Front yard and backyard were inspected. There was no obstruction to block the walkways.

The last time the facility conducted the emergency drill is 6/15/2024.

No deficiencies were noted today. 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: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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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