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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202758
Report Date: 12/08/2023
Date Signed: 12/10/2023 10:21:57 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/21/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230821165718
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:
12/08/2023
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Bernellet TaaTIME COMPLETED:
12:59 PM
ALLEGATION(S):
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Staff did not prevent resident from sexually assaulting another resident.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza conducted an unannounced visit to deliver the investigation finding and met with Administrator (ADM) Bernellet Taa.

On 08/21/2023, the Department received a complaint with the above allegation.

On 8/21/2003, resident R1 was interviewed. R1 stated he/she was sexually assaulted by resident R2. R1 stated he/she was unsure if the incident on 8/18/2023, but stated it happened at 2400 hours.

On 08/23/2023, the Department conducted an initial investigation visit. LPA requested the following documents : LIC500 personnel report, resident roster, resident physician reports and resident Appraisal Needs and Service Plan, resident emergency contacts and incident reports.

Continue on LIC9099-C. Page 1 of 3.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
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 5
Control Number 26-AS-20230821165718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758
VISIT DATE: 12/08/2023
NARRATIVE
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Staff did not prevent resident from sexually assaulting another resident:

On 10/05/2023, the Department conducted an interview with facility staff and residents.

On 08/21/2023, resident R1 was interviewed wherein he/she stated he/she was sexually assaulted by resident R2. R1 was unable to provide an accurate summary of the incident, nor could not explain the details. R1 provided contradictory statements. R1 initially agreed to complete a Sexual Assault Forensic Exam (SAFE) but then R1 became uncooperative and declined.

On 10/05/23, resident R2 was interviewed. R2 appeared alert but limited in his/her speech, but able to answer some questions. R2 stated he/she did not remember R1. R2 stated never kissed and/or touched residents, and never went into their bedrooms.

The Department conducted an interview with Administrator/Licensee (referred as ADM). ADM stated he/she stated that R1 suffers from hallucinations wherein R1 sees people like his/her relatives and starts speaking in a different language. ADM also stated that R1 talked to other residents but mostly with another male resident (R3). ADM stated that R1 never had a relationship with any of the residents and did not observe any inappropriate actions towards R1 by any of the residents, nor male residents were observed entering R1’s bedroom besides one time when R3 asked for a cigarette. ADM stated that R2 is not physically capable of the allegation as he/she described R2 as mentally and physically slow and feeble. ADM stated that R1 did not report to staff any abuse that happened to him/her, and R1 easily bruises but staff did not see any bruises on R1.



2 Out of 2 Staff (staff referred as S1 and S2) were interviewed. S1 stated that R1 did not have any close friends in the facility. S1 did not observe any inappropriate actions towards R1 by any of the residents. S1 also stated that he/she did not see any of the male/female residents enter R1’s bedroom. S2 stated that R1 has hallucination and confusion and had a change in behavior. S2 stated that R2 is slow, mild mannered and verbally limited and S2 did not observe any of the male/female residents enter R1’s bedroom and inappropriate actions towards R1 by any of the residents.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20230821165718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758
VISIT DATE: 12/08/2023
NARRATIVE
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 2 Out of 2 Residents were interviewed (referred as R3 and R4). R3 was not able to provide information regarding the incident. R4 stated that he/she does not know R1 very well and does not know if R1 had a romantic relationship with the other residents. R4 stated that R1 was friendly with another resident but did not observe any intimacy. R4 stated that he/she observed that R1 seemed to have a problem towards R2 and described R2 as real mellow and stays in his/her bedroom. R4 also added he/she never went inside R1’s bedroom and did not see any of the other residents enter R1’s bedroom.

The department has investigated the above allegation. Based on the records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur.



No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM.


Page 3 of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/21/2023 and conducted by Evaluator Chihhsien Chang
COMPLAINT CONTROL NUMBER: 26-AS-20230821165718

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:
12/08/2023
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Bernellet TaaTIME COMPLETED:
12:59 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not submit incident reports to licensing.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza conducted an unannounced visit to deliver the investigation finding and met with Administrator (ADM) Bernellet Taa.


On 08/23/2023, the Department conducted an initial investigation visit. LPA requested the following documents : LIC500 personnel report, resident roster, resident physician reports and resident Appraisal Needs and Service Plan, resident emergency contacts and incident reports.


Continue on LIC9099-C. Page 1 of 2.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20230821165718
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758
VISIT DATE: 12/08/2023
NARRATIVE
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Staff did not submit incident reports to licensing:

On 08/23/2023, the Department received an incident report that law enforcement officers came to the facility to investigate a sexual assault allegation regarding R1. Administrator (ADM) and staff were unaware of the allegations until law enforcement officers came the facility. .


Based on the records reviewed, The facility has submitted incident report to CCL office on 8/22/2023 and 8/23/2023.


The department has investigated the above allegation. Based on the records reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED.

No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM.


Page 2 of 2.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5