435202758-1-22-2026-26-AS-MPAA-DQKQQE-20260122112212

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 01/14/2026
Date Signed: 01/22/2026 11:22:25 AM

Document Has Been Signed on 01/22/2026 11:22 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 CENTER		FACILITY NUMBER:	435202758
ADMINISTRATOR/ DIRECTOR:	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: 4	DATE:	01/14/2026
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:15 PM
MET WITH:	Bernelett Taa - Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

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) Maria (Mita) Partoza conducted an unannounced case management - legal/non-compliance visit (NCC) and met with Administrator/Licensee (ADM/LIC) Bernellet Taa. The purpose of the visit is to ensure the facility is adhering to the compliance plan submitted to Community Care Licensing (CCL) after a non-compliance meeting held on 07/26/2024. During visit, LPA toured the facility inside and outside and accompanied by ADM/LIC the living room, kitchen, dining room, 3 resident bedrooms, resident bathroom, staff room, Administrator's office, and backyard. No cameras were observed inside the facility. The interior of the facility is maintained, organized and sanitary. LPA observed 2 staff (S1 & S2) working upon arrival and observed 2 residents watching TV. The exit door leading to the backyard and entrance door observed with a door alarm. Staff demonstrated how to operate the door alarms, in which LPA observed the alarms were in good working condition. The facility has no surveillance camera outside. LPA reviewed the facility scheduled activity calendar with corresponding activities for each day of the week. LIC/ADM stated 2 Out of 4 residents are able to leave the facility unassisted, are able to drive and have valid driver licenses. 3 out of 4 are in the facility, and 1 out of 4 is out attending prior commitments. Activities listed on the calendar are to promote the resident's mental, emotional and social functions of the residents in care. page 1 of 2 See LIC 809C

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 01/14/2026

NARRATIVE

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LPA inspected 3 resident bedroom 3 Out of 3 bedroom are shared, with storage for resident's personal belongings, resident bathroom, staff room and office room. Resident bathroom has grab bars and anti skid mats, sanitary and organized. 1 out 3 bedroom is set-up for bedridden and non-ambulatory individuals. Licensee is approved for 3 ambulatory, 2 non-ambulatory and 1 bedridden.

LPA reviewed the facility's LIC500, the facility has 2 main caregivers who lives at the facility. S1 and S2 are able to respond in case of an emergency. LIC/ADM is at the facility at least 20 hours per week. LIC/ADM stated that S1 as the main administrator of the facility and LIC/ADM will be a back-up administrator. There are two individuals listed on the LIC 500 that are family member of the licensee and staff. Both individuals are background and fingerprint cleared.

LPA reviewed 4 Out of 4 resident files and verified that records are current and updated such as but not limited to appraisal/needs and services plan, admission agreement, medical assessment, TB result, and signed personal rights forms. The resident's appraisal/needs and services plan have detailed information of the residents' care needs with the corresponding action to meet their needs.

LPA reviewed 2 staff files. The 2 main staff members (S1 and S2) has current active 1st aid certification and updated training on topics to include such as but not limited to medication training, Alzheimer/dementia care, nutrition, and caregiver staff training. Staff health screening is complete and has cleared TB test.

LPA reinforced the importance of adhering to the facility's corrective plan of action developed on 07/26/2024 to LIC/ADM to ensure that the facility stays in compliance with California Code of Regulations (CCR) Title 22. LIC/ADM was reminded that the facility will be monitored for the next two years from the date of the NCC meeting starting 07/26/2024.

No deficiencies were cited per California Code of Regulations, Title 22. An exit interview was conducted with Administrator, Bernellet Taa and a copy of the report was provided.

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end of report

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Maria Partoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2026

LIC809 (FAS) - (06/04)

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