435202758-5-22-2024-26-AS-KHOS-D6JH6Q-20240624055531

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202758
Report Date: 05/21/2024
Date Signed: 05/22/2024 08:03:54 AM

Unfounded

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
08/19/2022 and conducted by Evaluator Chihhsien Chang

COMPLAINT CONTROL NUMBER: 26-AS-20220819134416

FACILITY NAME:	EXCELSIOR HEALTHCARE CENTER		FACILITY NUMBER:	435202758
ADMINISTRATOR:	TAA, BERNELLET C		FACILITY TYPE:	740
ADDRESS:	5359 BIRCH GROVE DRIVE		TELEPHONE:	(408) 229-2680
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95123
CAPACITY:	6	CENSUS: 5	DATE:	05/21/2024
		UNANNOUNCED	TIME BEGAN:	11:29 AM
MET WITH:	Bernellet Taa		TIME COMPLETED:	12:01 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff took resident's personal property.
Facility is charging resident at random.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LicensingProgram Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced investigation visit to deliver the investigation findings, and met with Administrator (ADM) Bernellet Taa.

On 08/19/2022, the Department received a complaint with the above allegations.

On 08/2/4/2022, the Department conducted an initial investigation visit.

LPA interviewed ADM, 2 staff, and 4 residents (R1 - R4).

LPA requested Admission Agreement, facility rules, resident Physician's Report, Apprasil Needs and Service Plans, Rosters of residents and staff.

Continue on LIC9099-C. Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

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 3

Control Number 26-AS-20220819134416

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: 05/21/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Staff took resident's personal property:

On 08/19/2022, the Department received a complaint with the allegation that the facility staff took resident's personal property. It has been alleged facility staff took a resident's cell phone.

On 08/24/2022, LPA interviewed Administrator (ADM). ADM stated residents can use the facility phone and can use their cell phone without restriction. ADM stated only resident R1 has cell phone.

ADM stated on 8/16/2022, resident R1 stated his/her cell phone was not working. ADM stated R1 gave his/her cell phone to ADM to figure out why. ADM stated he/she charged R1's cell phone overnight. ADM stated he/she returned R1's cell phone on 8/17/2022 around 8:00AM - 8:30PM to R1. ADM stated on 8/18/2022, R1 told him/her that R1 was unable to find R1's cell phone. ADM stated on 8/18/2022, he/she found R1's cell phone on R1's bed.

LPA interviewed resident R1. R1 stated the facility ADM took his/her cell phone for 3 days in the middle of August 2022. R1 stated after that 3 days, he/she can use the cell phone. R1 stated he/she can use the facility phone.

LPA interviewed 4 residents. 4 out of 4 stated facility did not take their personal property. 4 out 4 residents stated they did not know facility staff take resident's cell phone.

LPA interviewed 2 staff. 2 out 2 staff stated the residents can use the facility phone and cell phone without restriction. Both stated only R1 has cell phone.

A review of R1's physician report dated 6/5/2020, R1 has mild cognitive impairment, visual impairment, confusion,.and becoming forgetful. A review of R1's Appraisal Needs and Service Plan dated 03/09/2022, R1 is forgetting where his/her things, and forgetful and confused.

Based on interviews and records reviewed, no evidence to indicate that the facility staff took R1's cell phone.

Continue on LIC9099-C. Page 2 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20220819134416

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: 05/21/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facility is charging resident at random:
On 08/19/2022, the Department received a complaint with the allegation that the facility Facility is charging resident at random. It has been alleged facility charges resident to transport him/her to the bank.

On 8/24/2022, LPA interviewed 4 resident (R1 - R4). R1 stated he/she was charged $30 by ADM 5 years ago when he/she asked the facility to provide the transportation to bank. R2 stated ADM charged him/her $50 to and from bank. R3 and R4 stated the facility does not charge extra money.

LPA interviewed 2 staff. 2 out of 2 staff stated the facility does not charge residents for extra money.

LPA interviewed Administrator (ADM). ADM stated the facility charges residents on the transportation for medical/dental and other appointments $25 per hour plus milage. ADM stated the facility notified the residents when they were admitted and it was specified in the Admission Agreement.

A review of R1's Admission Agreement dated 6/29/2020, the transportation for medical/dental and other appointments section on page 9 was initiated by R1 and the Admission Agreement was signed by R1. A review of R2's Admission Agreement dated 10/27/2021, the transportation for medical/dental and other appointments section on page 9 was initiated by R2.

The transportation section of the Admission Agreement specifies: "The facility shall provided assistance or make arrangements in meeting residents necessary medical and other appointment needs. If the facility is asked to provide transportation, the resident shall bill $25 per hour and milage."

Based on the interviews, and records reviewed, no evidence to indicate the facility is charging resident at random.

The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis.

Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM. Page 3 of 3.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Chihhsien Chang
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3