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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 05/14/2024
Date Signed: 05/14/2024 02:40:11 PM

Document Has Been Signed on 05/14/2024 02:40 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:EXCELSIOR HEALTHCARE CENTERFACILITY NUMBER:
435202758
ADMINISTRATOR/
DIRECTOR:		TAA, BERNELLET CFACILITY TYPE:
740
ADDRESS:5359 BIRCH GROVE DRIVETELEPHONE:
(408) 229-2680
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 5DATE:
05/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:53 AM
MET WITH:Bernellett C Taa - AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 5/14/2024 at 8:53 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived at the facility and conducted an unannounced required 1 year annual inspection and met with the administrator (ADM) Bernelette Taa. LPA stated the purpose of the visit.

The facility is a Residential Care Facility for the Elderly (RCFE) catering residents from ages 60 and above, who are ambulatory, with physical and mental functional limitations. The facility current residents is 5 (R1 to R5) and 1 staff at the time of the visit. 2 out of 5 resident is not in the facility. ADM stated R1 has a scheduled medical appointment and R2 is out walking. 2 staff (S2 and S3) are not in the facility. 1 out of 2 staff is on-call basis or as needed. 1 out of 2 staff is currently on a leave of absence with no projected time of return as stated by the ADM.

At 9:20 a.m. LPA with ADM toured the facility inside and outside, including but not limited to the kitchen, dining room, bathroom, living room, resident's rooms, office area, backyard and garage. LPA observed that the residents just finished their breakfast. LPA observed 2 days of perishable food and the refrigerator temperature is at 38 degree F and freezer at 0 degree F. LPA observed that the kitchen, dining room, and living area are accessible and are free of debris at the time of the inspection.

LPA observed, that the laundry area is in the garage. The garage stores the cleaning supplies, laundry detergents, knives and other chemicals. The garage has a separate storage for 7 days of non-perishable food. The door to access the garage has a code keypad lock and remained locked during the time of inspection.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/14/2024
NARRATIVE
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LPA observed that 1 bathroom is shared by 5 residents. 1 bathroom is used by staff. The bathroom has skid mats and grab bars, the water temperature ranges from 105 degree f to 113.7 degree F. LPA observed the toilet seat has a safety rail/grab bar attached. The back area of the toilet seat rail/grab bar has corrosion and rust.

LPA observed that exit doors are easily accessible and free from obstructions. The backyard has a pool with no water, fenced in and not accessible. At the side of the building is a fifth wheel trailer and not accessible.
The facility temperature is at 69.7 degree F. Smoke and carbon monoxide alarms are in good working condition. The fire extinguisher was replaced on 4/5/2024. LPA observed that medications are locked and are not accessible to residents. The fire drill and disaster training was last conducted on 5/3/2024.

LPA observed 3 out of 5 (R3 to R5) were at the facility, 1 out of 3 was watching TV, 1 out of 3 was on the exercise bike. LPA observed an individual in the staff room. ADM stated that the individual is a relative and is fingerprint and background cleared. LPA checked guardian and the individual is cleared on 4/30/2024.

LPA reviewed 3 resident file and 1 staff record. During the document review, LPA observed that 2 out of 5 resident was under the age of 60 (R3 and R4).

Deficiencies were cited during today's visit per California Code of Regulations (CCR) Title 22. See LIC 809D. An exit interview was conducted during today's visit. A copy of the report and appeals rights were provided.

end of report
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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 05/14/2024 02:40 PM - It Cannot Be Edited


Created By: Maria Partoza On 05/14/2024 at 01:51 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above by not maintaining a clean, safe, sanitary and in good repair and condition the toilet seat rail/grab bar which pose/poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2024
Plan of Correction
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Administrator stated that the toilet seat rail/grab bar will be replaced by the end of the day and will send proof of correction by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/14/2024 02:40 PM - It Cannot Be Edited


Created By: Maria Partoza On 05/14/2024 at 02:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87455(b)(7)
87455 Acceptance and Retention Limitations (b) The following persons may be accepted or retained in the facility: (7) Persons who are under 60 years of age whose needs are compatible with other residents in care, if they require the same amount of care and supervision as do the other residents in the facility. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, R3 and R4 are both under the age of 60. The facility has a census of 5 and capacity of 6. ADM did not send exception request prior to admitting the R3, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/29/2024
Plan of Correction
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ADM stated that an exception request will be submitted to LPA with the required information that states the compatibility of R3 with other residents in care.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Romeo Manzano
LICENSING EVALUATOR NAME:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2024


LIC809 (FAS) - (06/04)
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