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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201041
Report Date: 09/10/2021
Date Signed: 09/11/2021 12:00:39 PM

Document Has Been Signed on 09/11/2021 12:00 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 IIIFACILITY NUMBER:
435201041
ADMINISTRATOR:RICHARDS, SHIRLEYFACILITY TYPE:
735
ADDRESS:4280 DULCEY DRIVETELEPHONE:
(408) 300-1688
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 6DATE:
09/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Shirley Richards, ADMTIME COMPLETED:
09:50 AM
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Licensing Program Analyst (LPA) Steve Chang, licensing Program Manager (LPM) Romeo Manzano, and Program Clinical Consultant (PCC) Lori Kopplinger conducted Technical Assistant -PCC through tele-inspection (Zoom),and met with Administrator (ADM) Shirley Richards.

The purpose of this TA PCC Tele visit was to review the facility COVID-19 infection mitigation plan and conducted inspection of the facility to ensure plan is being carried out and to provide support and guidance to staff in mitigating the spread of virus.

During tele-visit inspection, a tour of the facility was conducted which started at the main entrance to check COVID-19 signage and screening procedures. The facility has the COVID-19 posters at the main entrance to include screening questionnaire forms, hand sanitizer, face masks, thermometer, glove, and a visitor log book.

The facility common areas were inspected such as the kitchen, living room, family room, dining area, bathrooms were observed. No all the trash cans with cover were observed. There are 4 resident bedrooms, 2 staff live-in bedroom, and 2 bathrooms in facility. Facility bathrooms signage on hand washing, hand sanitizer, paper towels were observed, and trash cans were observed. The laundry room was observed and inspected. The resident bedrooms were inspected. The beds in the shared rooms were observed in 6 feet apart. PPE supplies, and disinfect supplies were inspected. Medication closet, and detergent closet were observed locked.

ADM stated all the residents and staff are fully vaccinated. ADM stated the residents were checked body temperature twice per day.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 III
FACILITY NUMBER: 435201041
VISIT DATE: 09/10/2021
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Based on today's inspection, the facility is being recommended the following:

1. A designated staff to check COVID symptoms for all the staff and residents daily.

2. Facility to wipe and disinfect high touch areas.

3. Towels in kitchen and bathrooms must be remove due to contamination.

4. Bar soap in bathrooms or kitchen must be used instead facility to use pump anti-bacterial hand soap.

5. Recommend trash cans/bins with foot pedal in bathrooms and kitchen.

6. ADM to replace CDC signage on procedures of doffing and donning of PPEs in facility. CDC signage was provided to the facility.

7. ADM to schedule for N95 fit testing for staff. This is OSHA requirement for facilities with positive COVID-19.

8. Recommend cleaning/disinfecting products which are EPA approved with one minute sit/wet wait time.

No deficiencies cited during today's Tele Visit. Exit interview conducted with Administrator.
A copy of this report emailed to the facility for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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