Excelsior Healthcare Center

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management - legal/non-compliance visit (NCC) and met with licensee/administrator (LIC) Bernellet Taa and assigned administrator (ADM/S1) Thelma Laserna. 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 1 out of 6 is taking a shower, 4 out of 6 were in their room resting, and 1 out of 6 was 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 6 residents are able to leave the facility unassisted, 1 out of 6 is able to drive and have valid driver licenses. 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 LPA inspected 4 resident bedroom prior staff room has been converted to a single occupancy for ambulatory resident. 2 out of the 4 resident bedroom are single occupancy (Rooms 1 & 3) and 2 out of the 4 are shared (2a, 2b, 4a, 4b) The room have storage for resident's personal belongings, resident bathroom. Resident bathroom has grab bars and anti skid mats, sanitary and organized. 1 out of 4 bedroom is approved for 1 bedridden and non-ambulatory individuals. Licensee is approved for 6 ambulatory, 2 of the 6 can be non-ambulatory and 1 out of 6 can be bedridden and 2 out of 6 can be under hospice care. 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 designated administrator of the facility and LIC/ADM will be the main administrator on record. There are two individuals listed on the LIC 500 that are family member of the licensee and staff. Staff have cleared criminal background and fingerprint. LPA reviewed 3 Out of 6 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). 1 out of 2 has current active 1st aid certification. 2 out of 2 has 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. S2 is currently attending classes at National Alliance for Mental Illness (NAMI) course for health care providers for mental illness as part of the compliance for staff. 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. page 2 of 2the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced annual required inspection and met with designated Administrator (DADM) Thelma Laserna and stated the purpose of the visit. Licensee/Administrator (LIC/ADM) Bernelett Taa was not present at the time of the visit due to prior commitment. The facility is licensed for adults 60 and over 3 ambulatory and 2 may be non-ambulatory and 1 bedridden. LPA observed 1 staff, 2 residents watching television in the living room, 1 resident was is being assisted with their activity of daily living (ADLs), 1 was in their room resting and 1 was out with family. LPA toured the facility, including common areas, resident rooms, kitchen, bathrooms, driveway, and outdoor spaces and storage areas. Indoor temperature was within acceptable range of 70°F. The kitchen was sanitary and organized; knives and chemicals were locked. Food supply met requirements (2 days perishable, 7 days non-perishable). Kitchen water temperature measured at 105°F. Bathroom water temperature ranged from 105°F to 110°F. Bathrooms had grab bars and non-skid mats; resident rooms had adequate storage. Residents rooms have storage that is sufficient to store their personal items. Residents room were kept organized and sanitary. Medications were locked and inaccessible to residents; first aid kit was complete. Outdoor areas were free of hazards; laundry appliances were functional, and cleaning supplies were secured. Fire, smoke, and carbon monoxide systems were operational; hallways were clear of any tripping hazard and well-lit. page 1 of 2 The facility has door alarm system, emergency kit packs for each resident, first aid kit was complete and alarm system on the outdoor gate. The facility is equipped with carbon monoxide and alarm system that were operational. The facility an empty swimming pool that is fenced in and not accessible to resident. LPA reviewed resident and staff records, including medication logs, admission agreements, care plans, personal and incidentals, health screenings, and training. All staff have required clearances and certifications. The facility conducts fire and earthquake drill quarterly for each shift. Last drill practice training was conducted 02/05/26 and 04/08/26. The facility is equipped with fire extinguisher in the kitchen area. No deficiencies were cited during today's visit based on the California Code of Regulations (CCR) Title 22. An exit interview was conducted with DADM Thelma Laserna and a copy of the report was provided. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Jun 5, 2026

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Maria (Mita) Partoza conducted an unannounced case management - legal/non-compliance visit (NCC) and met with licensee/administrator (LIC) Bernellet Taa and assigned administrator (ADM/S1) Thelma Laserna. 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 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 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 administrator of the facility and LIC/ADM will be a back-up administrator and the main administrator on record. 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 5 Out of 5 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. S1 is currently attending classes at National Alliance for Mental Illness (NAMI) course for health care providers for mental illness as part of the compliance for staff. 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. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Apr 22, 2026

Type of visit: Case Management - Legal/Non-compliance

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 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. page 2 of 2 end of reportthe state’s words, verbatim · CDSS document, Jan 14, 2026

Type of visit: Case Management - Legal/Non-compliance

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, garage, and backyard. No cameras were observed inside the facility. The interior of the facility is maintained, organized and sanitary. LPA observed 1 caregiver/staff (S1) working in the facility 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. 1 Out of 4 likes doing indoor activities and walks around the neighbor. 1 Out of 4 is accompanied by his/her family member and walks around the neighborhood. Activities listed on the calendar are to promote the resident's mental, emotional and social functions of the residents in care. 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. 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 he/she is the process of assigning 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.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced case management inspection of the facility for compliance. LPA met with Licensee/Administrator Bernelette Taa and stated the purpose of the visit. The purpose of this inspection is to ensure that the facility is in compliance with Title 22. LPA reviewed with the licensee/administrator regarding the recommendations discussed during NCC meeting on 7/26/2024. LPA toured the facility inside and outside with the Licensee to include resident rooms, kitchen, living room, and back yard. LPA observed the facility to be clean, safe, sanitary and in good repair for the safety of residents, staff and visitors. LPA observed door alarms at the top of the living room sliding glass door, top of the door in the hallway leading to the backyard, and on the wooden gate in the back yard on the side of the house. All door alarms functioned properly (audible alarm) when tested by the Licensee. LPA reviewed 3 staff records. 3 out of 3 staff records have fingerprint clearance, medical assessment with TB result, and staff training. LPA reviewed 4 resident records. 4 out of 4 resident records have updated service plans, physician's reports. LPA reviewed the LIC 500 and facility has sufficient coverage for the number of residents in the facility. No deficiencies were cited during today's inspection per Title 22 Code of Regulations and an exit interview was conducted with the Licensee/ Administrator Bernelett Taa. A signed copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 13, 2025

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility and grounds of this RCFE for mentally disabled elderly. There is a swimming pool in backyard, but it is surrounded by a metal fence about 5 feet high. No fire safety hazards are observed. There are 3 shared bedrooms for residents and 2 bathrooms--one designated for residents. In addition, there are 2 staff rooms--one is occupied by 3 live-in staff and the other is an office with a bed for administrator/licensee. There is a detached storage shed in backyard. Washer and dryer are located in the attached two car garage. Carbon monoxide detector is tested and operable. There are 4 exit doors--3 of which exit to fenced yard. There is an alarm on front door, but it is NOT secured. Exit gate from backyard to street is alarmed, but is NOT secured. Door from garage is accessed by a passcode. Facility has fire clearance for secured perimeter. . Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Hot water temperature tested at 105 degrees in clients' bathroom. Soap and paper towels are present in bathrooms and kitchen sink. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 4 residents present, and 3 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact are reviewed, as well as other staff and client records. Personal and incidental cash transaction records are maintained accurate, including safeguarded cash for 4 residents. Bernellet Taa a certified RCFE administrator (x 8/25) that oversees facility operations. Continued on next page. The following forms/information are requested to be updated and submitted to CCLD by 7/7/25: - Administrative Organization (LIC309) - Designation of Administrative Responsibility (LIC308) - Affiavit regarding Client Cash Resources (LIC400) - bedridden plan of operation - medication training requirements for staff - proof of current liability insurance Emergency Disaster Plan (LIC610E) is provided to LPA today. No deficiencies of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, are cited. See Technical Advisory Notes--2 pages--for additional information.the state’s words, verbatim · CDSS document, Jun 23, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analyst (LPA) Christine Kabariti arrived unannounced to conduct the facility case management - legal/non-compliance visit (NCC). LPA met with Administrator, 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 with staff (S1) to include the living room, kitchen, dining room, 3 resident bedrooms, resident bathroom, staff bedroom, staff bathroom, Administrator's office, garage, and backyard. No cameras observed inside of the facility. LPA did not observe any concerns regarding the cleanliness of the facility. There was only 1 caregiver/staff (S1) working in the facility upon arrival. LPA observed a total of 3 live-in individuals who are all fingerprint cleared and associated to the facility roster. 1 out of the 3 individuals (S1) is a staff/caregiver of the facility. The 2 live-in individuals are family members of S1 and does not assist with any caregiver duties. S1 states the 2 individuals just help to clean the facility. Based on the facility's LIC500, the facility only has 2 main caregivers who work 7 days a week. S1 and S2 covers each other during break times to ensure the residents have staff supervision at all time. Based on the schedule and Administrator, there are certain times of the day where S1 and S2 are both present. Administrator is working on training another staff (S4) before starting work at the facility. A copy of the LIC500 obtained. SEE LIC809-C. 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 operable. On 01/27/2025, the Department issued the facility a deficiency due to the Licensee altering the facility's building and grounds without proper notification to the Department and building permits. The Administrator corrected the deficiency and submitted their plan of correction to the Department. During today's visit, LPA observed the all partition walls were removed and the facility's physical plant matches the facility sketch approved by the Department. LPA reviewed 4 out of 4 resident files. 4 out of 4 resident files contained a signed and updated appraisal/needs and services plan from 02/03/2025, admission agreement, medical assessment, TB result, and signed personal rights form. The resident's appraisal/needs and services plan includes detailed information regarding the resident's care needs & what the facility is doing to meet their needs, LPA reviewed 4 staff files. The 2 main staff members (S1 and S2) obtains an active 1st aid certification and updated training on topics to include (but not limited to) medication training, Alzheimer/dementia care, nutrition, and caregiver staff training. 4 out of 4 staff members has a health screening and TB result. LPA advised Administrator regarding the importance of adhering to the facility's corrective action plan that was developed on 07/26/2024 to ensure the facility's stays within compliance of Title 22 regulation. Administrator was reminded of the discussion on 07/26/2024 of the facility being under frequent monitoring inspection visits to ensure compliance with the compliance plan and Title 22 Regulations for 2 years. No deficiencies were cited per California Code of Regulations, Title 22. This report was reviewed with Administrator, Bernellet Taa and a copy of the report was provided.the state’s words, verbatim · CDSS document, May 30, 2025

Allegation investigated: Staff engaged in an inappropriate relationship with a resident in care.

Unannounced complaint visit made out to this facility on 03/08/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Bernellet Taa, who was briefly interviewed at this time. Current census was (4) residents. The purpose of this visit was to deliver the findings of this investigation to this facility, and it's designated representative, at this time. Based on interviews and a review of the forms and documents that were retrieved during this investigation, it was learned that resident, R1, initially moved into this facility several years prior to the employment of staff person, S1, at this facility. Based on interviews conducted, It was learned that the facility residents and facility staff were unclear if there was a relationship building and taking place while S1 was employed in assisting to take care of R1. It was learned that facility residents and facility staff were equally shocked when R1 decided to move out with S1 since they had gotten married and could no longer reside at this facility. Substantiated Based on an interview conducted with the facility designated Administrator, Benellet Taa, it was learned that she did not know about the ongoing relationship that was taking place between R1 and S1. It was learned that she did not know about the marriage between R1 and S1 until it was announced to all facility personnel and residents by R1 that a decision had been made and that R1 had decided to move out with S1 back in July 2024. Based on an interview conducted with the facility designated Administrator, Benellet Taa, it was learned and admitted in her statements that she felt responsible for the relationship taking place and should have been more diligent in monitoring her staff and residents. It was learned that she admitted that the relationship should never have gained traction and that if she was more proactive in the day to day operations of this facility she might have been able to make some impact and could have possibly changed the outcome of this relationship in the end. It was learned that she admitted that the relationship should not have taken place and accepted responsibility that one of her staff members engaged in a relationship with a facility resident who was vulnerable and susceptible to not making the best decisions and could have been taken advantage of as a result. As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met. The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes. Appeal rights were printed and a copy was given to the facility designated Administrator at this time. Exit Interviewthe state’s words, verbatim · CDSS document, Mar 8, 2025 · control 26-AS-20241108164008

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(a) · Plan of correction due date: Mar 9, 2025

All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This facility was found to be deficient as evidenced by this facility designated Administrator not being aware of a relationship developing between a facility resident and staff person which resulted in a marriage and eventual move out which posed an immediate threat to the Health, Safety, and Personal Rights to the residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2025

Plan of correction: The facility designated Administrator stated that he/she will undergo training, for no less than one hour in duration, on the subject matter of facility residents rights and how to properly maintain them at all times. A statement of correction, along with copies of the updated training, will be completed and submitted into CCL by the due date. Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(3)(E) · Plan of correction due date: Mar 9, 2025

All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 The training shall include, but not be limited to, the following: Psychosocial needs of the elderly, such as recreation, companionship, independence, etc. This facility was found to be deficient as evidenced by the allowance of a facility staff person engaging in a relationship with a facility resident requiring care and supervision which posed an immediate threat to the Health, Safety, and Personal Rights of all residents in care.the state’s words, verbatim · CDSS document, Mar 8, 2025

Plan of correction: The facility designated Administrator stated that all facility staff will undergo training, for no less than one hour in duration, on the subject matter of facility residents rights and how to properly maintain them at all times. A statement of correction, along with copies of the updated training, will be completed and submitted into CCL by the due date. Proof of completed training will involve the topic of training, name of the vendorized trainer, and list of attendee(s).

Type of visit: POC

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.the state’s words, verbatim · CDSS document, Feb 13, 2025

Type of visit: Case Management - Legal/Non-compliance

Licensing Program Analysts (LPAs) Manuel Monter, Kenneth Madrigal & Licensing Program Manager (LPM) Romeo Manzano conducted an unannounced Case Management- Legal/Non-compliance(NCC). LPAs met with Administrator (ADM) Bernelette Taa and stated the purpose of the visit. The purpose of this inspection was to ensure that the facility is in compliance with Title 22 Regulations and the compliance plan stated on LIC9111 NCC on 7/262024. LPA conducted a random review of 4 resident (R1 to R4) and 2 (S1 to S2) staff files, and toured the facility inside and out. During visit, LPA observed the staff room directly across to the dining area has been converted into two bedrooms/partition [1 for a resident and 1 for a staff (S1)]. On 11/18/2024, LPA observed 1 of the converted bedroom was occupied 1 male resident (R1) wherein a citation was not issued at the time of visit due to time constraint but discussed it with Administrator/licensee. Based on a review of STD850 issued on 1/30/2020 by the SJ Fire clearance and facility floor plan approved for 5 bedrooms including staff designated bedroom. ADM stated she did not obtain building permit prior to the building alterations. ADM stated R1 just no longer resides in the staff bedroom, as of January 26, 2025. In addition, while touring bedroom #3 and master bedroom , LPA observed a partition wall inside bedroom#3 and a little office (Photographs were taken) with no building permit including converting master bedroom into bedroom and a main master bedroom door was removed to expand as a hallway. These building alterations are not reflected on the submitted and approved fire clearance and physical plant in 2020. Further review of the STD850, the facility does not have a 'delayed egress,' a secure perimeter or is a locked perimeter with an exception of the swimming pool inaccessible to residents with 5 foot fence and is padlocked. CCLD will clarify and resubmit facility fire clearance to SJFD. Page 1 Out of 3. LPA conducted a staff file review for S1 to S5 S1's file was reviewed. S2's 1st Aid and CPR training has expired since 06/24/2024. health screening. S2 does not have a completed health screening signed by a physician. S3, S4 and S5 does not have a file. ADM stated that staff training on mental illness was conducted in 2024. ADM stated that staff training for 2025 is in progress. LPAs/LPM also review facility staffing. ADM (S3) stated that she has 1 full-time staff (S1) who works 5 days a week (730am to 12pm and 2pm to 6pm) with 3 hours break (12-2pm) during and is live-in. ADM stated that she lives in the facility, M to F from 12pm to 8am and on weekends 7pm to 7am; ADM's daughter visits once or twice a week; daughter is not an employee and her brother who comes to sleep once a week. Both ADM's daughter and brother has criminal background clearance. ADM stated that her husband (S4), who is a co-licensee, who works only on Fri and Sat 730am to 7pm, and 1 staff (S2) who works only on the weekends, 7am to 7pm. ADM's designated on-call administrator (referred as S5), does not have a file in the facility. ADM stated she will update CCL with any changes to the LIC500. During visit, LPAs/LPM assessed staff knowledge such as but not limited to mental illness, neurocognitve disorder and responding to emergency situation. S1 is able to respond to some of the questions. LPAs/LPM informed licensee to ensure that staff are provided in-service in the level that they understand. Also, the importance of maintaining staff files including training log (i.e., hours, date, trainees, topic). LPAs/LPM reviewed R1 to R4's LIC625 Appraisal Needs and Services Plan with ADM, LPAs/LPM advised ADM to have a method of evaluating residents' progress, such as data tracking. LPAs informed ADM to complete and update all the residents Appraisal Needs and Services Plans; detailing the residents care needs & what the facility is doing to meet their needs, and to ensure that residents' LIC625 is signed by the resident or residents' responsible party and licensee. During today's visit, LPAs/LPM observed two surveillance camera located, in the kitchen and living room area. ADM stated the video camera has the ability to record audio and video, but ADM clarified that the cameras are not recording audio. ADM removed cameras during visit. LPAs' informed licensee about, infringement of residents personal rights. LPAs' advised ADM to submit a program plan if she wishes to continue using video surveillance inside the facility. Page 2 Out of 3. LPAs' advised ADM if she requires a POC extension,she must send a written request to CCLD on or before the POC date by providing the following the reason and new POC date. Failure to complete/submit POC before due date may result to Civil Penalty. Deficiencies were cited during today's inspection and an exit interview was conducted with the licensee/ administrator Bernelett Taa. A copy of the report was provided. Appeal Rights were provided.the state’s words, verbatim · CDSS document, Jan 27, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87305(a) · Plan of correction due date: Feb 3, 2025

87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidence by; Based on tour and floor plan review, staff bedroom across dining room converted to a resident and staff bedroom , bedroom #3 and the master bedroom has partition walls inside each of them without blding permits/fire clearance. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: ADM stated she will send LPA a written plan of action the existing partitions with no building permits/fire clearance. ADM will submit POC on or before February 3, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(g) · Plan of correction due date: Feb 3, 2025

87412 Personnel Records (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review. This Requirement was not met as evidenced by Based on record review, ADM stated she did not have staff records for her on-call Administrator. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: ADM stated she will send a written letter of understanding regarding about ensuring personnel records are available at the facility. ADM stated she will send to LPA by POC date, February 3, 2025.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(c)(1) · Plan of correction due date: Feb 3, 2025

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. This requirement was not met as evidenced by; Based on record review and interview, S2's first aid training/cpr trainining expired 6/2024. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: ADM stated ADM will schedule S2 to obtain first aid/CPR training. S2 is allowed to work but with another staff who has a valid first aid/CPR on duty. ADM will submit evidence of S1's training on or before POC date. ADM stated she will send documentation showing, Staff S2 had completed his/her first aid training. ADM stated she will send the plan of correction by POC date, February 3, 2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87411(f) · Plan of correction due date: Feb 3, 2025

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.... This requirement was not met as evidenced by; Based on interview and record review, Staff S2 does not completed heath screening signed by his/her physician though there is a TB/x-ray done. This poses/posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jan 27, 2025

Plan of correction: ADM stated she will have staff S2 complete a health screening. S2 stated she will send LPA a copy of a completed health screening. ADM stated she will also send a letter of understanding regarding the regulation. ADM stated she will send the plan of correction to have S2 obtain health screening LPA by POC date, February 3, 2025.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Manuel Monter arrived unannounced to open a complaint investigation. During the complaint investigation for the complaint 26-AS-20241108164008, a case management deficiencies visit was conducted due to violations discovered during the investigation process. LPA met with Administrator Bernellet Taa. On November 18, 2024, Licensing Program Analyst Manuel Monter conducted an unannounced complaint investigation visit. LPA requested a copy of R1's Admission Agreement, Physician's Report, Assessment, progress notes and Service Plans. ADM stated she cannot find the residents binder. ADM stated she would look for the documents and send them once she finds them. Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Bernellet Taa. A copy of the report was provided. Appeal rights were provided.the state’s words, verbatim · CDSS document, Nov 18, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(d) · Plan of correction due date: Nov 25, 2024

87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, ... during normal business hours.... This requirement was not met as evidenced by; Based on interview conducted, ADM stated she could not find R1's file. ADM stated she looked for it but could not provide to LPA to inspect/ Audit. This pose/poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Nov 18, 2024

Plan of correction: ADM stated she will send a written letter of understanding regarding the regulation and the importance of having residents records avalable to inspect/ audit. ADM stated she wil send the plan of correction by POC date, November 25, 2024.

Type of visit: Case Management - Other

Licensing Program Analysts (LPAs) Maria (Mita) Partoza and Marcella Tarin conducted an unannounced case management inspection of the facility for compliance. LPAs met with licensee/administrator Bernelette Taa and stated the purpose of the visit. This inspection visit was to ensure that the facility is in compliance with Title 22. LPA reviewed with the licensee/administrator regarding the recommendations discussed during NCC. LPA conducted a random review of resident and staff files, and toured the facility inside and outside. LIC/ADM stated that 3 staff have completed the 15 hour Course for Provider Mental Illness Education through National Alliance for Mental Illness (NAMI), 3 staff are enrolled to attend class and pending confirmation. Door alarms were observed at the front door. Orders for additional door alarms were placed and expected to be delivered on 10/31/2024 to be placed on exit doors. LPAs reviewed the LIC 500 and facility has sufficient coverage for the number of residents in the facility. LPAs reviewed residents file and found them to be current updated. No deficiencies were cited during today's inspection and an exit interview was conducted with the licensee/ administrator Bernelett Taa. A copy of the report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2024

Type of visit: Office

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.the state’s words, verbatim · CDSS document, Jul 26, 2024

Allegation investigated: Staff took resident's personal property. Facility is charging resident at random.

LicensingProgram Analysts (LPAs) Steve Chang and Manuel Monter conducted an unannounced investigation visit to deliver the investigation findings, and met with Administrator (ADM) Bernellet Taa. On 08/19/2022, the Department received a complaint with the above allegations. On 08/2/4/2022, the Department conducted an initial investigation visit. LPA interviewed ADM, 2 staff, and 4 residents (R1 - R4). LPA requested Admission Agreement, facility rules, resident Physician's Report, Apprasil Needs and Service Plans, Rosters of residents and staff. Continue on LIC9099-C. Page 1 of 3. Unfounded Staff took resident's personal property: On 08/19/2022, the Department received a complaint with the allegation that the facility staff took resident's personal property. It has been alleged facility staff took a resident's cell phone. On 08/24/2022, LPA interviewed Administrator (ADM). ADM stated residents can use the facility phone and can use their cell phone without restriction. ADM stated only resident R1 has cell phone. ADM stated on 8/16/2022, resident R1 stated his/her cell phone was not working. ADM stated R1 gave his/her cell phone to ADM to figure out why. ADM stated he/she charged R1's cell phone overnight. ADM stated he/she returned R1's cell phone on 8/17/2022 around 8:00AM - 8:30PM to R1. ADM stated on 8/18/2022, R1 told him/her that R1 was unable to find R1's cell phone. ADM stated on 8/18/2022, he/she found R1's cell phone on R1's bed. LPA interviewed resident R1. R1 stated the facility ADM took his/her cell phone for 3 days in the middle of August 2022. R1 stated after that 3 days, he/she can use the cell phone. R1 stated he/she can use the facility phone. LPA interviewed 4 residents. 4 out of 4 stated facility did not take their personal property. 4 out 4 residents stated they did not know facility staff take resident's cell phone. LPA interviewed 2 staff. 2 out 2 staff stated the residents can use the facility phone and cell phone without restriction. Both stated only R1 has cell phone. A review of R1's physician report dated 6/5/2020, R1 has mild cognitive impairment, visual impairment, confusion,.and becoming forgetful. A review of R1's Appraisal Needs and Service Plan dated 03/09/2022, R1 is forgetting where his/her things, and forgetful and confused. Based on interviews and records reviewed, no evidence to indicate that the facility staff took R1's cell phone. Continue on LIC9099-C. Page 2 of 3. Facility is charging resident at random: On 08/19/2022, the Department received a complaint with the allegation that the facility Facility is charging resident at random. It has been alleged facility charges resident to transport him/her to the bank. On 8/24/2022, LPA interviewed 4 resident (R1 - R4). R1 stated he/she was charged $30 by ADM 5 years ago when he/she asked the facility to provide the transportation to bank. R2 stated ADM charged him/her $50 to and from bank. R3 and R4 stated the facility does not charge extra money. LPA interviewed 2 staff. 2 out of 2 staff stated the facility does not charge residents for extra money. LPA interviewed Administrator (ADM). ADM stated the facility charges residents on the transportation for medical/dental and other appointments $25 per hour plus milage. ADM stated the facility notified the residents when they were admitted and it was specified in the Admission Agreement. A review of R1's Admission Agreement dated 6/29/2020, the transportation for medical/dental and other appointments section on page 9 was initiated by R1 and the Admission Agreement was signed by R1. A review of R2's Admission Agreement dated 10/27/2021, the transportation for medical/dental and other appointments section on page 9 was initiated by R2. The transportation section of the Admission Agreement specifies: "The facility shall provided assistance or make arrangements in meeting residents necessary medical and other appointment needs. If the facility is asked to provide transportation, the resident shall bill $25 per hour and milage." Based on the interviews, and records reviewed, no evidence to indicate the facility is charging resident at random. The Department has investigated the above allegations. Based on the investigation, records reviewed, and interviews conducted, the Department found that the above allegations are UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Exit interview was conducted with ADM. The report was provided to ADM for signature. A copy of the report was provided to ADM. Page 3 of 3.the state’s words, verbatim · CDSS document, May 21, 2024 · control 26-AS-20220819134416

Type of visit: Required - 1 Year

On 5/14/2024 at 8:53 a.m. Licensing Program Analyst (LPA) Maria (Mita) Partoza arrived at the facility and conducted an unannounced required 1 year annual inspection and met with the administrator (ADM) Bernelette Taa. LPA stated the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE) catering residents from ages 60 and above, who are ambulatory, with physical and mental functional limitations. The facility current residents is 5 (R1 to R5) and 1 staff at the time of the visit. 2 out of 5 resident is not in the facility. ADM stated R1 has a scheduled medical appointment and R2 is out walking. 2 staff (S2 and S3) are not in the facility. 1 out of 2 staff is on-call basis or as needed. 1 out of 2 staff is currently on a leave of absence with no projected time of return as stated by the ADM. At 9:20 a.m. LPA with ADM toured the facility inside and outside, including but not limited to the kitchen, dining room, bathroom, living room, resident's rooms, office area, backyard and garage. LPA observed that the residents just finished their breakfast. LPA observed 2 days of perishable food and the refrigerator temperature is at 38 degree F and freezer at 0 degree F. LPA observed that the kitchen, dining room, and living area are accessible and are free of debris at the time of the inspection. LPA observed, that the laundry area is in the garage. The garage stores the cleaning supplies, laundry detergents, knives and other chemicals. The garage has a separate storage for 7 days of non-perishable food. The door to access the garage has a code keypad lock and remained locked during the time of inspection. page 1 LPA observed that 1 bathroom is shared by 5 residents. 1 bathroom is used by staff. The bathroom has skid mats and grab bars, the water temperature ranges from 105 degree f to 113.7 degree F. LPA observed the toilet seat has a safety rail/grab bar attached. The back area of the toilet seat rail/grab bar has corrosion and rust. LPA observed that exit doors are easily accessible and free from obstructions. The backyard has a pool with no water, fenced in and not accessible. At the side of the building is a fifth wheel trailer and not accessible. The facility temperature is at 69.7 degree F. Smoke and carbon monoxide alarms are in good working condition. The fire extinguisher was replaced on 4/5/2024. LPA observed that medications are locked and are not accessible to residents. The fire drill and disaster training was last conducted on 5/3/2024. LPA observed 3 out of 5 (R3 to R5) were at the facility, 1 out of 3 was watching TV, 1 out of 3 was on the exercise bike. LPA observed an individual in the staff room. ADM stated that the individual is a relative and is fingerprint and background cleared. LPA checked guardian and the individual is cleared on 4/30/2024. LPA reviewed 3 resident file and 1 staff record. During the document review, LPA observed that 2 out of 5 resident was under the age of 60 (R3 and R4). Deficiencies were cited during today's visit per California Code of Regulations (CCR) Title 22. See LIC 809D. An exit interview was conducted during today's visit. A copy of the report and appeals rights were provided. end of report page 2the state’s words, verbatim · CDSS document, May 14, 2024

Type of visit: Case Management - Incident

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 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) 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. Page 3 of 4 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. page 4 of 4 End of Reportthe state’s words, verbatim · CDSS document, Feb 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87461(a)(5) · Plan of correction due date: Feb 24, 2024

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. 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.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87405(d)(1)to(7) · Plan of correction due date: Feb 24, 2024

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. 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.the state’s words, verbatim · CDSS document, Feb 23, 2024

Plan of correction: 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.

Allegation investigated: Staff did not prevent resident from sexually assaulting another resident.

Licensing Program Analysts (LPAs) Steve Chang and Mita Partoza conducted an unannounced visit to deliver the investigation finding and met with Administrator (ADM) Bernellet Taa. On 08/21/2023, the Department received a complaint with the above allegation. On 8/21/2003, resident R1 was interviewed. R1 stated he/she was sexually assaulted by resident R2. R1 stated he/she was unsure if the incident on 8/18/2023, but stated it happened at 2400 hours. On 08/23/2023, the Department conducted an initial investigation visit. LPA requested the following documents : LIC500 personnel report, resident roster, resident physician reports and resident Appraisal Needs and Service Plan, resident emergency contacts and incident reports. Continue on LIC9099-C. Page 1 of 3. Unsubstantiated Staff did not prevent resident from sexually assaulting another resident: On 10/05/2023, the Department conducted an interview with facility staff and residents. On 08/21/2023, resident R1 was interviewed wherein he/she stated he/she was sexually assaulted by resident R2. R1 was unable to provide an accurate summary of the incident, nor could not explain the details. R1 provided contradictory statements. R1 initially agreed to complete a Sexual Assault Forensic Exam (SAFE) but then R1 became uncooperative and declined. On 10/05/23, resident R2 was interviewed. R2 appeared alert but limited in his/her speech, but able to answer some questions. R2 stated he/she did not remember R1. R2 stated never kissed and/or touched residents, and never went into their bedrooms. The Department conducted an interview with Administrator/Licensee (referred as ADM). ADM stated he/she stated that R1 suffers from hallucinations wherein R1 sees people like his/her relatives and starts speaking in a different language. ADM also stated that R1 talked to other residents but mostly with another male resident (R3). ADM stated that R1 never had a relationship with any of the residents and did not observe any inappropriate actions towards R1 by any of the residents, nor male residents were observed entering R1’s bedroom besides one time when R3 asked for a cigarette. ADM stated that R2 is not physically capable of the allegation as he/she described R2 as mentally and physically slow and feeble. ADM stated that R1 did not report to staff any abuse that happened to him/her, and R1 easily bruises but staff did not see any bruises on R1. 2 Out of 2 Staff (staff referred as S1 and S2) were interviewed. S1 stated that R1 did not have any close friends in the facility. S1 did not observe any inappropriate actions towards R1 by any of the residents. S1 also stated that he/she did not see any of the male/female residents enter R1’s bedroom. S2 stated that R1 has hallucination and confusion and had a change in behavior. S2 stated that R2 is slow, mild mannered and verbally limited and S2 did not observe any of the male/female residents enter R1’s bedroom and inappropriate actions towards R1 by any of the residents. Continue on LIC9099-C. Page 2 of 3. 2 Out of 2 Residents were interviewed (referred as R3 and R4). R3 was not able to provide information regarding the incident. R4 stated that he/she does not know R1 very well and does not know if R1 had a romantic relationship with the other residents. R4 stated that R1 was friendly with another resident but did not observe any intimacy. R4 stated that he/she observed that R1 seemed to have a problem towards R2 and described R2 as real mellow and stays in his/her bedroom. R4 also added he/she never went inside R1’s bedroom and did not see any of the other residents enter R1’s bedroom. The department has investigated the above allegation. Based on the records reviewed, and interviews conducted, the Department found that the above allegation is UNSUBSTANTIATED. An unsubstantiated finding indicates that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the allegations did or did not occur. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM. Page 3 of 3. Staff did not submit incident reports to licensing: On 08/23/2023, the Department received an incident report that law enforcement officers came to the facility to investigate a sexual assault allegation regarding R1. Administrator (ADM) and staff were unaware of the allegations until law enforcement officers came the facility. . Based on the records reviewed, The facility has submitted incident report to CCL office on 8/22/2023 and 8/23/2023. The department has investigated the above allegation. Based on the records reviewed, and interviews conducted, the Department found that the above allegation is UNFOUNDED. No deficiencies or citations noted at today’s compliant investigation visit. Exit interview conducted with ADM. A copy of this report was provided to ADM. Page 2 of 2.the state’s words, verbatim · CDSS document, Dec 8, 2023 · control 26-AS-20230821165718