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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435201751
Report Date: 02/28/2024
Date Signed: 02/28/2024 08:56:20 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/28/2024 08:56 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:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:39 PM
MET WITH:Daisy ConsultaTIME COMPLETED:
12:59 PM
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Licensing Program Analyst (LPA) Steve Chang conducted an unannounced annual inspection today. Upon arrival, a female Daisy Consulta (DC) opened the door for LPA. DC stated there is no resident in facility.

LPA toured the facility inside and out with DC. Living room, family room, dining room, kitchen, and garage were observed. Two restrooms were observed in the facility. 1 office, 3 bedrooms, 1 storage room and 1 master bedroom with a restroom inside were observed.

No resident or staff was observed in facility and in the backyard.

The house is in non operational status.

LPA talked to Administrator (ADM Shirley Richards on the phone. ADM stated she cannot get back to the facility at this time. ADM authorized DC to sign the report. LPA suggested ADM to close the facility if the facility is in non operational status.

Exit interview was conducted with DC. This report was provided to DC for signature. A copy of the report was provided to DC.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE: DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/28/2024
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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