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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 07/26/2024
Date Signed: 07/26/2024 11:25:07 AM


Document Has Been Signed on 07/26/2024 11:25 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 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:
07/26/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bernellet Taa - Administrator/CEOTIME COMPLETED:
11:30 AM
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A Noncompliance meeting was conducted on July 26, 2024 at CCLD San Jose office. Present at the meeting were San Bruno Adult and Senior Care Regional Manager (RM) Vivien Helbling, Licensing Program Manager (LPM) Romeo Manzano, Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcela Yanez, Administrator/CEO of Excelsior Healthcare Inc., (ADM/CEO) Bernellet Taa and Janet Kempis, Excelsior Healthcare Inc, Board Member/Secretary (virtual participation).

The purpose of the noncompliance meeting was to discuss the history of facility's serious violations cited under Title 22 California Code of Regulations to include mental condition 87461(a)(5), administrator qualification 87405 (d) (1)(7) and maintenance and operation, 87303 (a)

Noncompliance Conference Summary LIC 9111 and compliance plans were established during the meeting. The facility will begin a 2 year monitoring plan by licensing which includes more frequent licensing inspections.

The San Bruno Adult and Senior Care - San Jose Unit will refer the facility for legal consultation which may result in administrative actions such as possible Administrator De-Certification, License Revocation, or Employee Exclusion.

The Licensee was informed during non-compliance meeting that additional civil penalties for serious bodily injury are pending review.

During the meeting, Janet Kempis, introduced herself as the facility consultant. Upon review of the CA Secretary of State electronic filing, Ms. Kempis is a board member/secretary of the corporation that was filed on 1/28/2021. Ms. Kempis denied that she is a board member of the corporation (Excelsior Healthcare Inc) . Ms. Taa stated that Ms. Kempis is a board member of the corporation. Ms. Taa stated that Mr. Emmanuel Taa is still the vice president of the corporation and inadvertently did not include Mr. Taa's name when she filed in 1/28/2021. RM Helbling informed Ms. Taa and Ms. Kempis that the information needs to reflect the true members of the board with the CA Secretary of State and submit an updated LIC 301 (Administrative Organization).

Report was reviewed with Bernellet Taa CEO/Administrator. A copy of this report, LIC 9111 was provided to Ms. Taa during today's office visit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Maria PartozaTELEPHONE: (669) 308-3994
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2024
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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