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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201751
Report Date: 03/28/2022
Date Signed: 03/28/2022 04:18:47 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/28/2022 04:18 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 IVFACILITY NUMBER:
435201751
ADMINISTRATOR:SHIRLEY RICHARDSFACILITY TYPE:
735
ADDRESS:4392 CLEARPARK PLACETELEPHONE:
(408) 281-2334
CITY:SAN JOSESTATE: CAZIP CODE:
95136
CAPACITY: 6CENSUS: 0DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Shirley RichardsTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection today. Upon arrival, a female Lolita Macabadbad (LM) opened the door for LPA. LM stated there is no resident in facility. LPA called administrator (ADM) Shirley Richards. ADM stated ADM will be at facility in 5 minutes. LPA waited at outside for 5 minutes.

ADM stated the facility is non operational. ADM stated ADM and ADM's aunt LM live in this house. LPA did not see any COVID poster at the door, or at the main entrance or in the facility. There is no screening station in the house.

LPA toured the facility inside out with ADM. Living room, family room, dinning room, kitchen were observed. Two restrooms were observed. One office, 4 bedrooms, and one master bedroom were observed. No resident or staff was observed in facility.

The house was in non operational status. LPA suggested ADM to close the facility if the facility is in non operational status.

Exit interview was conducted with ADM. This report was provided to ADM for signature.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2022
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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