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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435200828
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:42:48 PM

Document Has Been Signed on 02/04/2025 03:42 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:
02/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:50 PM
MET WITH:Shirley RichardsTIME VISIT/
INSPECTION COMPLETED:
03:18 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met with Administrator (ADM) Shirley Richards.

The purpose of today's visit is to follow up with the incident report Community Care Licensing office received on 1/17/2025. The incident occurred on 1/16/2025 around 9:12AM. Resident R1 attacked resident R2 on the head. R1 was sent to hospital.

LPA interviewed staff S1. S1 stated on 1/16/25, at 9:10AM, he/she helped resident R2 to shave in the dining room. R2 and R3 were talking in loud which made resident R1 unhappy. R1 asked R2 and R3 to be quiet. R2 and R3 were quiet when they saw R1. R1 assaulted R2 on R2's head. S1 stated R2 was bleeding. S1 called ADM immediately. ADM came in the facility immediately. ADM called 911 when ADM arrived at the facility. S1 stated police officers came and they took R1.

LPA interviewed ADM. ADM stated on 1/16/2025, he/she received a phone call from staff around 9:15AM regarding the incident between R1 and R2. ADM stated he/she arrived at the facility around 9:20AM. ADM stated he/she assessed R1 and R2, and called 911 around 9:25AM. ADM stated paramedics and police came. R2 was sent to hospital. ADM stated police officers took R1 in custody. ADM stated R1 does not return to the facility yet. ADM stated the facility issued a 30 day eviction letter to R1.

LPA requested R1's physician report, appraisal needs and service plan, and Individual program plan (IPP). LPA requested R2's discharge medical document.

This case need further 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: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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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