<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 11/18/2024
Date Signed: 11/18/2024 11:34:13 AM

Document Has Been Signed on 11/18/2024 11:34 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/
DIRECTOR:		TAA, BERNELLET CFACILITY TYPE:
740
ADDRESS:5359 BIRCH GROVE DRIVETELEPHONE:
(408) 229-2680
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 4DATE:
11/18/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Administrator Bernellet TaaTIME VISIT/
INSPECTION COMPLETED:
11:35 AM
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
Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to open a complaint investigation. During the complaint investigation for the complaint 26-AS-20241108164008, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Bernellet Taa.

On November 18, 2024, Licensing Program Analyst Manuel Monter conducted an unannounced complaint investigation visit. LPA requested a copy of R1's Admission Agreement, Physician's Report, Assessment, progress notes and Service Plans. ADM stated she cannot find the residents binder. ADM stated she would look for the documents and send them once she finds them.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Bernellet Taa. A copy of the report was provided. Appeal rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/18/2024 11:34 AM - It Cannot Be Edited


Created By: Manuel Monter On 11/18/2024 at 11:05 AM
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: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2024
Section Cited
CCR
87506(d)

1
2
3
4
5
6
7
87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, ... during normal business hours....
This requirement was not met as evidenced by;
1
2
3
4
5
6
7
ADM stated she will send a written letter of understanding regarding the regulation and the importance of having residents records avalable to inspect/ audit.

ADM stated she wil send the plan of correction by POC date, November 25, 2024.
8
9
10
11
12
13
14
Based on interview conducted, ADM stated she could not find R1's file. ADM stated she looked for it but could not provide to LPA to inspect/ Audit. This pose/poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2