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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202758
Report Date: 03/06/2023
Date Signed: 03/06/2023 04:00:56 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/01/2023 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20230301162452
FACILITY NAME:EXCELSIOR HEALTHCARE CENTERFACILITY NUMBER:
435202758
ADMINISTRATOR:TAA, BERNELLET CFACILITY TYPE:
740
ADDRESS:5359 BIRCH GROVE DRIVETELEPHONE:
(408) 229-2680
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 6DATE:
03/06/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Bernellet TaaTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff poured hot water on resident's body.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced initial complaint investigation visit and met with Administrator (ADM) Bernellet Taa.

During visit, LPA Marrufo interviewed residents R1-R4. Resident R5 refused to be interviewed and R6 was not present at the facility during visit. LPA Marrufo also interviewed staff S1-S3 and ADM Taa. During interviews, R1 stated that staff S1 threw a pot of hot water at R1 sometime before the year 2020, resulting in hot water falling on R1's chest, stomach, and legs. R1 stated to have suffered burns, but was not hospitalized for the burns. Residents R2-R4 stated to have never observed a staff pouring hot water on a resident or have experienced a staff pouring hot water on them.

See LIC9099-C for more information. Page 1 of 2.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 26-AS-20230301162452
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758
VISIT DATE: 03/06/2023
NARRATIVE
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Staff S1 stated during interview to have brought a coffee mug with hot water to R1. S1 stated S1 attempted to place the coffee mug on R1's bedroom table, but R1 moved the table right before S1 was going to place the coffee mug on the table, resulting in the coffee mug spilling. S1 stated about half the water from the coffee mug spilled out. S1 stated some of the water spilled on R1's stomach area and there was a visible stain of water on R1's shirt. S1 stated to have asked R1 if R1 was hurt by the hot water and R1 said no. S1 stated to have told R1 S1 could take R1 to the hospital if the hot water burned R1, but R1 declined. S1 stated to have checked R1 for burns immediately and again that night and the next day and did not observe any burns. S1 stated to be certain to have used a coffee mug and not a stove pot.

Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated.

No deficiencies were cited under California Code of Regulations Title 22.

This report was reviewed with ADM Taa and a copy of the report was provided.


Page 2 of 2. END REPORT.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2