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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202597
Report Date: 07/17/2020
Date Signed: 07/17/2020 03:50:01 PM

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:WESTWIND MEMORY CAREFACILITY NUMBER:
445202597
ADMINISTRATOR:KAREN TRAVISFACILITY TYPE:
740
ADDRESS:160 JEWELL STREETTELEPHONE:
(831) 421-9100
CITY:SANTA CRUZSTATE: CAZIP CODE:
95060
CAPACITY:59CENSUS: 47DATE:
07/17/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Debbie Johnston, Clinical Support SpecialistTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Jackie Jin conducted a Case Management Tele-Visit. LPA met with Debbie Johnston, Clinical Support Specialist via ZOOM.

During today's visit LPA discuss the current visitation policy and procedures for the facility. LPA toured the facility to ensure health protocols are still being followed and postings of universal precautions were posted. LPA also toured the visitation area for residents and families.

LPA requested the Clinical Support Specialist to send a picture of the isolation room to CCL by 07/20/2020;

This report was reviewed with Debbie Johnston, Clinical Support Specialist. A copy of this report will be emailed to Debbie Johnston, Clinical Support Specialist on 07/17/2020 for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020
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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