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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 10/22/2024
Date Signed: 10/27/2024 08:25:10 PM

Document Has Been Signed on 10/27/2024 08:25 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: 4DATE:
10/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:50 PM
MET WITH:Bernelett C TaaTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
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Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcella Tarin conducted an unannounced case management inspection of the facility for compliance. LPAs met with licensee/administrator Bernelette Taa and stated the purpose of the visit.

This inspection visit was to ensure that the facility is in compliance with Title 22. LPA reviewed with the licensee/administrator regarding the recommendations discussed during NCC. LPA conducted a random review of resident and staff files, and toured the facility inside and outside. LIC/ADM stated that 3 staff have completed the 15 hour Course for Provider Mental Illness Education through National Alliance for Mental Illness (NAMI), 3 staff are enrolled to attend class and pending confirmation. Door alarms were observed at the front door. Orders for additional door alarms were placed and expected to be delivered on 10/31/2024 to be placed on exit doors.

LPAs reviewed the LIC 500 and facility has sufficient coverage for the number of residents in the facility.
LPAs reviewed residents file and found them to be current updated.

No deficiencies were cited during today's inspection and an exit interview was conducted with the licensee/ administrator Bernelett Taa. A copy of the report was provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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