<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202597
Report Date: 03/24/2022
Date Signed: 03/24/2022 12:00:14 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2020 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20200813162506
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: DATE:
03/24/2022
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:TIME COMPLETED:
12:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to monitor resident's condition and failed to report to responsible parties
Lack of personal care resulting in toe nail infection
Facility failed to follow the resident's care plan
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced visit to deliver the complaint investigation findings. LPA met with Administrator Steven Silacci.

During the course of the investigation, the department interviewed 2 individuals, 1 staff member and 1 family member and reviewed facility documents including 3 resident physician's reports, 3 resident needs and services plan, resident progress notes, photographs of the facility, and resident doctor's notes.

In review of resident records. 1 out of 3 records physician's reports were last updated in 2018 despite resident having resided in the facility beyond 2019. Facility does not have an updated resident assessment or physician's report. 1 out of 3 physician's reports reviewed indicated that a resident living at the facility (R1) had a history of treatments for superficial skin cancers.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 26-AS-20200813162506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 445202597
VISIT DATE: 03/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During interview with facility administrator and review of staffing roster, LPA determined that staff members of relevant interest to the complaint no longer work at the facility, and thus could not be interviewed.

In doctor's notes received by the department, R1 had developed a mole while in the care of the facility which was diagnosed as squamous cell carcinoma. Review of facility progress notes do not indicate that the facility had detected R1's cancerous mole. In review of R1's resident service plan dated 04/19/2019, it was indicated that the facility would conduct daily skin checks to monitor for potential re-emergence of skin cancer. In review of licensed nurse evaluation, R1 was indicated as having unexpected weight loss on 12/19/2019, R1's progress notes do not indicate that R1's responsible person was informed of weight loss, nor do they indicate detection of squamous cell carcinoma. R1's responsible person stated in an interview that they were never informed about R1's weight loss and that facility staff did not discover squamous cell carcinoma.

Further review of progress notes do not indicate the discovery or monitoring of ingrown toe nail/infection observed and photographed by family. Review of R1's care plan indicates that the facility had agreed to provide assistance in incidental health and medical care, which would include assistance with overgrown/ingrown toe nails and toe nail infections. Review of resident medical records indicate that R1's doctor prescribed daily exercise including walks for R1. Review of the resident's care plan and progress notes did not reflect updated prescription for resident exercise.

The Department has conducted an investigation of the above allegations. Based on records reviewed, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies are being cited. See LIC 9099-D.

Exit interview conducted with Administrator Steven Silacci. A copy of this report, along with the facility's appeals rights were provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 26-AS-20200813162506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 445202597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2022
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 - Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes... when changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the... responsible person. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility to conduct training with staff and med techs regarding monitoring of changes in conditions of resident as well as when to report changes of condition to responsible persons.
8
9
10
11
12
13
14
Based on interviews and records review, the facility did not report changes in condition to a resident's responsible party. This posed an immediate risk to the health and safety of residents in care.
8
9
10
11
12
13
14
Type A
03/25/2022
Section Cited
CCR
87468.2(a)(4)
1
2
3
4
5
6
7
87468.2 - Additional Personal Rights of Residents in Privately Operated Facilities - (a)...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights...(4) Care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Faciltiy to conduct training with staff and med techs regarding reading and understanding resident care plans as well as implementing a sign off indicating that staff has reviewed care plans.
8
9
10
11
12
13
14
Based on records review, facility staff did not follow resident's care plan, resulting in devlopment of multiple physical ailments. This posed an immediate risk to the health and safety of residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 26-AS-20200813162506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 445202597
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/01/2022
Section Cited
CCR
87464(f)(4)
1
2
3
4
5
6
7
87464(f)(4) - Basic Services - (f) Basic services shall at a minimum include... (4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications... this requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility to provide documentation of regular podietry appointments available to all residents intiated in 2021. Facility to provide in-service training on skin checks/full body checks by POC due date.
8
9
10
11
12
13
14
Based on records review, facility did not assist resident with clipping of toe nails when assistance was needed. This posed a potential risk to the health and safety of residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/13/2020 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20200813162506

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: DATE:
03/24/2022
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:TIME COMPLETED:
12:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has mold
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ryker Heberle conducted an unannounced visit to deliver the complaint investigation finding. LPA met with Administrator Steven Silacci.

During the course of the investigation, the department interviewed 2 individuals, 1 staff member and 1 family member and reviewed facility documents including 3 resident physician's reports, 3 resident needs and services plan, resident progress notes, photographs of the facility, and resident doctor's notes.

In review of photographs taken of resident belongs, a bottle of shampoo and a shower matt both visibly contained mold. However, it is unclear in the photographs where or when the photos of moldy belongings were taken.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 26-AS-20200813162506
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CARE
FACILITY NUMBER: 445202597
VISIT DATE: 03/24/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During inspections conducted by the Department ranging from the dates 08/24/2020 to 08/03/2021, Licensing Program Analysts Ryker Heberle and Eric Ng (LPAs), did not observe any mold to be present inside resident rooms, bathrooms, or in the common areas of the facility. The facility was observed to be clean and well maintained.

This Department has investigated the above allegation, and based on records review and observation the Department has determined that the allegation was Unsubstantiated, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

Exit interview conducted. This report was reviewed with Executive Director Steven Silacci and a copy was provided.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6