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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 09/06/2023
Date Signed: 09/06/2023 10:47:33 AM

Document Has Been Signed on 09/06/2023 10:47 AM - 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: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: 4DATE:
09/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:TAA, BERNELLET CTIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Christine Dolores arrived unannounced to conduct a case management - incident visit. LPA met with Administrator, Bernellet Taa.

The purpose of the visit was to obtain records. The following records were obtained to include resident (R1)'s physician's report, appraisal/needs and services plan, identification and emergency information, and personnel report.

This case management will be kept open pending investigation.

This report was reviewed with Administrator, Bernellet Taa and a copy of the report was provided.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Christine Dolores
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2023
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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