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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201041
Report Date: 02/13/2025
Date Signed: 02/13/2025 05:11:58 PM

Document Has Been Signed on 02/13/2025 05:11 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 IIIFACILITY NUMBER:
435201041
ADMINISTRATOR/
DIRECTOR:		RICHARDS, SHIRLEYFACILITY TYPE:
735
ADDRESS:4280 DULCEY DRIVETELEPHONE:
(408) 300-1688
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 4DATE:
02/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:39 AM
MET WITH:Shirley RichardsTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced case management - incident visit and met with Administrator (ADM).

On 2/12/2025, the Department received a incident report regarding a resident R1's death. R1 was found unresponsive in the bathroom.

LPA interviewed ADM, 1 resident and 3 staff. All other clients went to day program.

LPA toured resident rooms and restrooms.

LPA obtained R1's physician report, appraisal needs and service plan, Individual Program Plan.

This case needs 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: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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