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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 06/17/2021
Date Signed: 06/30/2021 10:28:45 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 5DATE:
06/17/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Katherine AldabaTIME COMPLETED:
04:55 PM
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Licensing Program Analyst (LPA) Yatfai Eric Ng conducted an unannounced infection control site visit today. LPA met with the Assistant Administrator Katherine Aldaba.

One central entry point was designated for all staff, residents, and visitors. A temperature screening station and sign in sheet were present at the entrance. Hand sanitizers were available. LPA was temperature checked before entering the facility. LPA toured the facility with Assistant Administrator.

The facility was observed to be in sanitary condition. All staff were observed to be wearing face masks.

Both restrooms observed to be adequately stocked with paper towels and hand soap. Trash bins with covers were available to use. Hand washing signs were observed to be present. Other COVID-19 prevention signs were posted on the hallway.

A plan for epidemic outbreak specific to COVID-19 mitigation plan report (LIC 808) was in file.

LPA reviewed the current Provider information Notices and current recommendation of COVID-19 prevention controls with Assistant Administrator.

Advisory notes were issued. See LIC 9102.

No deficiency cited during visit.

This report was reviewed with Assistant Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Yatfai NgTELEPHONE: (559) 410-0327
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
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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