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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 01/27/2025
Date Signed: 01/27/2025 06:51:46 PM

Document Has Been Signed on 01/27/2025 06:51 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:
01/27/2025
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Administrator Bernellet TaaTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Manuel Monter, Kenneth Madrigal & Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced Case Management- Legal/Non-compliance(NCC). LPAs met with Administrator (ADM) Bernelette Taa and stated the purpose of the visit.

The purpose of this inspection was to ensure that the facility is in compliance with Title 22 Regulations and the compliance plan stated on LIC9111 NCC on 7/262024. LPA conducted a random review of 4 resident (R1 to R4) and 2 (S1 to S2) staff files, and toured the facility inside and out.

During visit, LPA observed the staff room directly across to the dining area has been converted into two bedrooms/partition [1 for a resident and 1 for a staff (S1)]. On 11/18/2024, LPA observed 1 of the converted bedroom was occupied 1 male resident (R1) wherein a citation was not issued at the time of visit due to time constraint but discussed it with Administrator/licensee.

Based on a review of STD850 issued on 1/30/2020 by the SJ Fire clearance and facility floor plan approved for 5 bedrooms including staff designated bedroom. ADM stated she did not obtain building permit prior to the building alterations. ADM stated R1 just no longer resides in the staff bedroom, as of January 26, 2025. In addition, while touring bedroom #3 and master bedroom , LPA observed a partition wall inside bedroom#3 and a little office (Photographs were taken) with no building permit including converting master bedroom into bedroom and a main master bedroom door was removed to expand as a hallway. These building alterations are not reflected on the submitted and approved fire clearance and physical plant in 2020. Further review of the STD850, the facility does not have a 'delayed egress,' a secure perimeter or is a locked perimeter with an exception of the swimming pool inaccessible to residents with 5 foot fence and is padlocked. CCLD will clarify and resubmit facility fire clearance to SJFD.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
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 5
Document Has Been Signed on 01/27/2025 06:51 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/27/2025 at 02:22 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: 01/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2025
Section Cited
CCR
87305(a)

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by;
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ADM stated she will send LPA a written plan of action the existing partitions with no building permits/fire clearance. ADM will submit POC on or before February 3, 2025.
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Based on tour and floor plan review, staff bedroom across dining room converted to a resident and staff bedroom , bedroom #3 and the master bedroom has partition walls inside each of them without blding permits/fire clearance. This poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
02/03/2025
Section Cited
CCR87412(g)

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87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
This Requirement was not met as evidenced by
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ADM stated she will send a written letter of understanding regarding about ensuring personnel records are available at the facility. ADM stated she will send to LPA by POC date, February 3, 2025.
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Based on record review, ADM stated she did not have staff records for her on-call Administrator. This poses/posed a potential health, safety or personal rights risk to persons in care.
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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:Manuel Monter
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 01/27/2025 06:51 PM - It Cannot Be Edited


Created By: Manuel Monter On 01/27/2025 at 03:31 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: 01/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2025
Section Cited
CCR
87411(c)(1)

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87411 Personnel Requirements - General (c) (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by;
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ADM stated ADM will schedule S2 to obtain first aid/CPR training. S2 is allowed to work but with another staff who has a valid first aid/CPR on duty. ADM will submit evidence of S1's training on or before POC date.
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Based on record review and interview, S2's first aid training/cpr trainining expired 6/2024. This poses/posed a potential health, safety or personal rights risk to persons in care.
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 ADM stated she will send documentation showing, Staff S2 had completed his/her first aid training. ADM stated she will send the plan of correction by POC date, February 3, 2025.
Type B
02/03/2025
Section Cited
CCR87411(f)

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87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health... verified by a health screening...signed by the examining physician.... This requirement was not met as evidenced by;
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ADM stated she will have staff S2 complete a health screening. S2 stated she will send LPA a copy of a completed health screening. ADM stated she will also send a letter of understanding regarding the regulation.
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Based on interview and record review, Staff S2 does not completed heath screening signed by his/her physician though there is a TB/x-ray done. This poses/posed a potential health, safety or personal rights risk to persons in care.
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ADM stated she will send the plan of correction to have S2 obtain health screening LPA by POC date, February 3, 2025.
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: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
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: 01/27/2025
NARRATIVE
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LPA conducted a staff file review for S1 to S5

S1's file was reviewed. S2's 1st Aid and CPR training has expired since 06/24/2024. health screening. S2 does not have a completed health screening signed by a physician. S3, S4 and S5 does not have a file. ADM stated that staff training on mental illness was conducted in 2024. ADM stated that staff training for 2025 is in progress.

LPAs/LPM also review facility staffing. ADM (S3) stated that she has 1 full-time staff (S1) who works 5 days a week (730am to 12pm and 2pm to 6pm) with 3 hours break (12-2pm) during and is live-in. ADM stated that she lives in the facility, M to F from 12pm to 8am and on weekends 7pm to 7am; ADM's daughter visits once or twice a week; daughter is not an employee and her brother who comes to sleep once a week. Both ADM's daughter and brother has criminal background clearance. ADM stated that her husband (S4), who is a co-licensee, who works only on Fri and Sat 730am to 7pm, and 1 staff (S2) who works only on the weekends, 7am to 7pm. ADM's designated on-call administrator (referred as S5), does not have a file in the facility. ADM stated she will update CCL with any changes to the LIC500.

During visit, LPAs/LPM assessed staff knowledge such as but not limited to mental illness, neurocognitve disorder and responding to emergency situation. S1 is able to respond to some of the questions. LPAs/LPM informed licensee to ensure that staff are provided in-service in the level that they understand. Also, the importance of maintaining staff files including training log (i.e., hours, date, trainees, topic).

LPAs/LPM reviewed R1 to R4's LIC625 Appraisal Needs and Services Plan with ADM, LPAs/LPM advised ADM to have a method of evaluating residents' progress, such as data tracking. LPAs informed ADM to complete and update all the residents Appraisal Needs and Services Plans; detailing the residents care needs & what the facility is doing to meet their needs, and to ensure that residents' LIC625 is signed by the resident or residents' responsible party and licensee.

During today's visit, LPAs/LPM observed two surveillance camera located, in the kitchen and living room area. ADM stated the video camera has the ability to record audio and video, but ADM clarified that the cameras are not recording audio. ADM removed cameras during visit. LPAs' informed licensee about, infringement of residents personal rights. LPAs' advised ADM to submit a program plan if she wishes to continue using video surveillance inside the facility. Page 2 Out of 3.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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: 01/27/2025
NARRATIVE
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LPAs' advised ADM if she requires a POC extension,she must send a written request to CCLD on or before the POC date by providing the following the reason and new POC date. Failure to complete/submit POC before due date may result to Civil Penalty.

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. Appeal Rights were provided.
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Manuel Monter
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2025
LIC809 (FAS) - (06/04)
Page: 5 of 5