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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202758
Report Date: 02/13/2025
Date Signed: 02/13/2025 09:11:17 AM

Document Has Been Signed on 02/13/2025 09:11 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/
DIRECTOR:		TAA, BERNELLET CFACILITY TYPE:
740
ADDRESS:5359 BIRCH GROVE DRIVETELEPHONE:
(408) 229-2680
CITY:SAN JOSESTATE: CAZIP CODE:
95123
CAPACITY: 6CENSUS: 4DATE:
02/13/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:42 AM
MET WITH: Bernellet C Taa, Administrator (ADM)TIME VISIT/
INSPECTION COMPLETED:
09:15 AM
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On February 13, 2025 at 8:42 AM, Licensing Program Analysts (LPA), Kenneth Madrigal and Manuel Monter, conducted an unannounced Plan of Corrections (POC) visit and met with Bernellet C Taa, Administrator (ADM).

On January 27, 2025, a case management Legal Non-Compliance was conducted and the following deficiencies were cited:
  • 87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit.
  • 87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.
  • 87411 Personnel Requirements - General (c) (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
  • 87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health... verified by a health screening...signed by the examining physician...


On February 3, 2025, the Department received the Plan of Corrections submitted by ADM.

LPAs toured the facility inside and out. LPAs observed all partition walls removed from staff room, bedroom #3, and master bedroom. All of the deficiencies were cleared during visit.

This report was reviewed with ADM and a copy of the report was provided to ADM.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Kenneth Madrigal
LICENSING EVALUATOR SIGNATURE: DATE: 02/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/13/2025
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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