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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 02/23/2024
Date Signed: 04/29/2024 01:40:04 PM

Document Has Been Signed on 04/29/2024 01:40 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:TAA, BERNELLET CFACILITY TYPE:
740
ADDRESS:5359 BIRCH GROVE DRIVETELEPHONE:
(408) 229-2680
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 6DATE:
02/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
04:23 PM
MET WITH:Bernellett TaaTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza, conducted an unannounced case management visit to deliver the finding of the incident that occurred on 09/04/2023

On 9/5/2023, the Department received an incident report regarding the death of a resident herein referred to as R1.

On 9/14/2023, the department conducted a case management visit and met with Licensee/Administrator (LIC/ADM) Bernellet Taa and gathered the following documents that includes but not limited to Appraisal Needs and Services Plan (LIC 625) dated 08/18/2023. Physician’s Report (PR) dated 8/14/2023 and Personnel Report (3/11/2023).

On 9/4/2023, at around 1749 hours (5:49 P.M.) R1 left the facility without the staff’s knowledge. Staff were not aware that R1 did not come back to the facility until the morning of 9/5/23 at around 0900 (9:00 A.M.) S1 notified ADM that R1 was missing. ADM instructed staff to look for the resident inside and outside of the facility. S1 called the family member herein referred to as F1. F1 informed S1 that R1 is deceased and did not want to provide additional information.

On 9/6/2023, the facility’s video surveillance recording was viewed and showed R1 walking out of the facility’s front driveway at 1749 hours (5:49 P.M.) of 9/4/2023 unassisted.

Page 1 of 4 continued to LIC 809-C
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2024
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 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: 02/23/2024
NARRATIVE
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Based on the available information, on 9/5/2023 at 0947, S1 called law enforcement to report R1 as missing from the facility since 9/4/2023 (time unknown).

Based on the Physician’s Report (PR) dated 8/14/2023, R1’s primary diagnosis of mental disorder.

Based on the personnel report (LIC 500) dated 3/11/2023, ADM lives in the facility and is available from Monday to Sunday. There is no night shift scheduled as noted on the LIC 500 after 2000 hours. S1 is scheduled 0900 to 1300 and 1600 to 2000 Tuesday to Saturday. S2 is scheduled 0800 to 1200 and 1300 to 1700 Sunday to Thursday.

On 9/6/2023 an interview was conducted with ADM. ADM stated the facility has two live-in staff, herein referred to as S1 and S2. ADM stated the facility does not require a wake night staff, their residents are independent, but staff are available if residents need help.

On 9/6/2023, an interview was conducted with S1. S1 stated that he/she checks the residents around 1830 hours before going to bed at 1900 hours. S1 stated staff do not have a routine check at night and no supervision required because residents do not leave the facility at night once residents are in bed. S1 stated he/she was not aware that R1 was missing until the morning of 9/5/2023. S1 stated 2 weeks prior to the incident R1’s case manager (CM) mentioned to S1 that R1 has suicidal thoughts and to monitor R1.

On 9/6/2023, an interview was conducted with S2. S2 stated that R1 had dinner on 9/4/2023 at around 1630 to 1700 hours and looked like R1 had low energy. S2 stated that residents usually go to bed at 1830 hours, but some residents will stay up to watch TV. S2 stated that after serving dinner and is done with his/her shift, S2 goes to bed and does not check on the residents at night. S2 stated that in the morning of 9/5/2023, S2 noticed that R1 was not home and notified S1.

On 9/12/2023, a telephone interview was conducted with case manager (CM) of R1. CM stated that R1 has suicidal ideation and to not let R1 leave the facility on his/her own. CM stated that a risk assessment was conducted and expected R1’s needs will be met since the facility has 24-hour care and supervision.

page 2 of 4 (LIC 809C)
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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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: 02/23/2024
NARRATIVE
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On 11/03/2023, a follow up interview was conducted with ADM. ADM stated the facility has a curfew of 2000 hours and if residents did not return by the curfew time, the police (PD) and the responsible party (RP) will be contacted and file a missing person report with the PD. ADM stated the facility alarm is turned on at 2000 hours and staff ensures all residents are present before setting the alarm.

ADM was asked if there were changes observed with R1s behavior. ADM stated that a few days prior to the incident. ADM stated that he/she noticed that R1 lost his/her appetite and had a hard time urinating. ADM stated that R1 has been in the facility for less than 3 weeks and seems to look like he did not want to be in the facility.

On 11/3/2023, a follow up interview was conducted with S1. S1 stated the residents can leave the facility unassisted and reminds residents to sign in and out of the logbook. The facility has a curfew set for all residents at 2000 hours. S1 stated that staff turn on the door alarm set at 1830 hours. S1 stated that he/she will conduct a random check between 2100 to 2200 hours.

On 11/3/2023, an interview was conducted with resident (R2). R2 stated the curfew time for residents is 2000 hours. Staff do not conduct bed checks on residents at night. R2 stated residents he/she needs to sign out on the facility logbook when going out of the facility. he/she saw R1 leave the facility around 1900 hours but did not notify the staff.

On 11/3/2023, an interview was conducted with family herein referred to as F2. F2 stated staff were notified that R1 was making statements of self-harm but the facility did not have a protocol in place.

Based on R1’s appraisal needs and services plan, R1’s suicidal ideation has not been addressed.

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SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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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: 02/23/2024
NARRATIVE
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The Department has investigated the above allegation. Based on interviews and records review there is preponderance of evidence to prove the alleged violation did occur, therefore the allegation is SUBSTANTIATED.

Deficiencies are cited based on California Code of Regulations (CCR) Title 22. An exit interview was conducted with administrator Bernallette Taa and a copy of the report was provided Appeals rights was provided.

An immediate civil penalty in the amount of $500 was assessed today. Additional civil penalties for the violation resulting in serious bodily injury is pending further review.

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End of Report
SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Maria Partoza
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/29/2024 01:40 PM - It Cannot Be Edited


Created By: Maria Partoza On 02/23/2024 at 04:47 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: 02/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/24/2024
Section Cited
CCR
87461(a)(5)

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87461 Mental Condition (a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual(5) has a documented history of behaviors which may result in harm to self or others.
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Licensee/administrator stated the plan of correction (POC) will be submitted on the due date. LIcensee stated he/she will re-train staff regarding documentation and reporting to administrator not just verbally but also in writing. Administrator will create procedure for staff to monitor residents.
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This requirement is not met as evidenced by:

Based on documentations and records reviewed, there is no mental/medical health assessment to address R1’s condition.
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Type A
02/24/2024
Section Cited
CCR87405(d)(1)to(7)

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87405 Administrator - Qualifications and Duties(d) The administrator shall have the qualifications specified...Sections 87405(d)(1) to (7). If the licensee...all requirements for an administrator... (1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Licensee/administrator stated the plan of correction (POC) will be submitted on the due date. LIcensee stated he/she will have the resident re-evaluated by Evaluation Psychiatric Services (EPS). Licensee stated that any change in condition will be reported to the PCP and keep a record of the changes.
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This requirement is not met as evidenced by: Based on the records reviewed and interviews, ADM and staff did not address R1’s mental health condition when R1 was observed by staff ‘looked like R1 had a low energy and less appetite and hard time urinating” prior to the incident.
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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:Maria Partoza
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2024


LIC809 (FAS) - (06/04)
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