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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200828
Report Date: 12/27/2024
Date Signed: 01/03/2025 05:01:33 PM

Document Has Been Signed on 01/03/2025 05:01 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: 4DATE:
12/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:21 PM
MET WITH:Shirley RichardsTIME VISIT/
INSPECTION COMPLETED:
04:39 PM
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This is an amended report to amend the LIC809 report issued on 12/27/2024.

Licensing Program Analyst(LPA) Steve Chang conducted an unannounced case management - incident visit to delivered an amended case management - incident report and met with Administrator (ADM) Shirley Richards.

On 12/26/2024, the Department received an incident report regrading a resident blocked the other resident's bedroom door. Two staff intervened to separate two resident. Resident R1 called 911 and claimed staff S1 touch him/her on hip and waist with clothing.

LPA interviewed ADM. ADM stated police officers came on 12/24/2024 around 5:15PM. ADM stated after police officer's interview with staff and residents, police officers did not substantiate R1's allegation.

LPA interviewed staff S1 and resident R1. S1 stated he/she did not hit/touch R1. R1 did not want to talk about this.

On 12/30/2024, the Department received a complaint for this case.

The complaint is under investigation.

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: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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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