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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202758
Report Date: 03/08/2025
Date Signed: 05/20/2025 09:27:32 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20241108164008
FACILITY NAME:EXCELSIOR HEALTHCARE CENTERFACILITY NUMBER:
435202758
ADMINISTRATOR:TAA, BERNELLET CFACILITY TYPE:
740
ADDRESS:5359 BIRCH GROVE DRIVETELEPHONE:
(408) 229-2680
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY:6CENSUS: 4DATE:
03/08/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bernellet TaaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff engaged in an inappropriate relationship with a resident in care.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 03/08/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Bernellet Taa, who was briefly interviewed at this time.
Current census was (4) residents.
The purpose of this visit was to deliver the findings of this investigation to this facility, and it's designated representative, at this time.
Based on interviews and a review of the forms and documents that were retrieved during this investigation, it was learned that resident, R1, initially moved into this facility several years prior to the employment of staff person, S1, at this facility.
Based on interviews conducted, It was learned that the facility residents and facility staff were unclear if there was a relationship building and taking place while S1 was employed in assisting to take care of R1. It was learned that facility residents and facility staff were equally shocked when R1 decided to move out with S1 since they had gotten married and could no longer reside at this facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
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 4
Control Number 26-AS-20241108164008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758
VISIT DATE: 03/08/2025
NARRATIVE
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Based on an interview conducted with the facility designated Administrator, Benellet Taa, it was learned that she did not know about the ongoing relationship that was taking place between R1 and S1. It was learned that she did not know about the marriage between R1 and S1 until it was announced to all facility personnel and residents by R1 that a decision had been made and that R1 had decided to move out with S1 back in July 2024.
Based on an interview conducted with the facility designated Administrator, Benellet Taa, it was learned and admitted in her statements that she felt responsible for the relationship taking place and should have been more diligent in monitoring her staff and residents.
It was learned that she admitted that the relationship should never have gained traction and that if she was more proactive in the day to day operations of this facility she might have been able to make some impact and could have possibly changed the outcome of this relationship in the end.
It was learned that she admitted that the relationship should not have taken place and accepted responsibility that one of her staff members engaged in a relationship with a facility resident who was vulnerable and susceptible to not making the best decisions and could have been taken advantage of as a result.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.

The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20241108164008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
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, CA

FACILITY NAME: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2025
Section Cited
CCR
87405(a)
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All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient
number of hours to permit adequate attention
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The facility designated Administrator stated that he/she will undergo training, for no less than one hour in duration, on the subject matter of facility residents rights and how to properly maintain them at all times. A statement of correction, along with copies of the updated training, will be completed and
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to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation.
This facility was found to be deficient as evidenced by this facility designated Administrator not being aware of a relationship developing between a facility resident and staff person which resulted in a marriage and eventual move out which posed an immediate threat to the Health, Safety, and Personal Rights to the residents in care.
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submitted into CCL by the due date.
Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20241108164008
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: EXCELSIOR HEALTHCARE CENTER
FACILITY NUMBER: 435202758
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2025
Section Cited
CCR
87411(c)(3)(E)
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All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
The training shall include, but not be limited to, the following:
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The facility designated Administrator stated that all facility staff will undergo training, for no less than one hour in duration, on the subject matter of facility residents rights and how to properly maintain them at all times. A statement of correction, along with copies of the updated training, will be completed and
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Psychosocial needs of the elderly, such as recreation, companionship, independence, etc.
This facility was found to be deficient as evidenced by the allowance of a facility staff person engaging in a relationship with a facility resident requiring care and supervision which posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.
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submitted into CCL by the due date.
Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).
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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.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4