445202597-4-19-2023-26-AS-RHEE-CR2SAL-20230419134232

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 445202597
Report Date: 04/19/2023
Date Signed: 04/19/2023 01:42:42 PM

Document Has Been Signed on 04/19/2023 01:42 PM - 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:	WESTWIND MEMORY CARE		FACILITY NUMBER:	445202597
ADMINISTRATOR:	STEVEN SILACCI		FACILITY TYPE:	740
ADDRESS:	160 JEWELL STREET		TELEPHONE:	(831) 421-9100
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	59	CENSUS:	DATE:	04/19/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Steven Silacci		TIME COMPLETED:	01:51 PM

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	On 04/19/2023 Licensing Program Analyst (LPA) Ryker Heberle met with Steven Silacci for a case management visit to follow up on substantiated allegations regarding neglect/lack of supervision resulting in resident’s death. On February 1st, 2021, the Department concluded a complaint investigation which alleged the following allegations: Facility staff did not observe changes in resident's (R1) health condition, facility did not seek timely medical treatment for R1 after fall, and facility did not report incident which threatened the health and safety of R1. The allegations were substantiated, and the licensee was cited for violating the California Code of Regulations (CCR) Title 22, § 87411 Personnel Requirements - General, for failure of two staff members to provide services needed to address R1's needs. Staff did not report R1's fall to hospice agency, which affected the medical attention that R1 received, eventually resulting in R1's death. Licensee was further cited for CCR Tittle 22 § 87466, Observation of the Resident, for staff's failure to observe and assess a bruise and fracture that developed after R1's fall. In addition, Licensee was also cited for CCR Title 22 § 87211 Reporting Requirements, for failure to provide a written report documenting R1's fall to the Department within seven days of the initial incident. The investigation revealed that on August 12, 2020, R1 was found on the floor in R1’s room by facility caregivers (S1 and S2). S1 and S2 stated that while attempting to assist R1 from the floor, R1 refused to be touched and R1 was able to transfer from floor to bed without assistance. S1 and S2 agreed that R1 should be assessed by facility's Medical Technician (S3). S3 was called to assess R1 due to screaming and agitation.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: WESTWIND MEMORY CARE	FACILITY NUMBER: 445202597
	VISIT DATE: 04/19/2023

NARRATIVE

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S3 responded to R1's room, conducted a full body assessment, and checked vital signs. According to S3, R1 did not verbalize any pain during assessment, however, S2 reported observing R1 saying "Ow" prior to S3's assessment, so S3 contacted R1's hospice nurse. Hospice nurse advised medication administration for R1's comfort.

No incident report was written to document R1 being found on the floor. Based on facility records, R1 has a history of falls. On March 28, 2020, and April 20, 2020, the facility had written incident reports for finding R1 "sitting on the floor."

R1's responsible party (RP) and hospice care nurse (HCN) were interviewed. RP and HCN stated they were not informed of R1 being found on the floor on August 12, 2020, and possibly having an unwitnessed fall. Based on hospice care notes, HCN was informed by facility staff that on August 12, 2020, R1 was yelling when being assisted by staff for bed. Notes did not indicate report from staff that R1 was found on the floor that day. Hospice case notes showed R1 was observed with a new bruise on left pelvis/hip on August 14, 2020, and the cause is "unknown". On August 14, 2020, August 15, 2020, and August 17, 2020, R1 was observed to have pain with movement.

On August 13, 2020, R1's health continued to decline until R1's death on August 21, 2020. An autopsy was conducted by the County Coroner. The autopsy revealed that R1 had broken ribs consistent with the time frame of August 12, 2020, to August 21, 2020. Autopsy was unable to confirm if R1's fractures caused R1's death.

R1's hospice care plan was reviewed. R1's hospice admission diagnoses dated December 9, 2019, were Alzheimer's disease, dementia, and osteoporosis without current pathological fracture.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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: WESTWIND MEMORY CARE	FACILITY NUMBER: 445202597
	VISIT DATE: 04/19/2023

NARRATIVE

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Based on interviews of facility staff, two staff had knowledge of R1 being found on the floor on August 12, 2020. Both staff failed to report the incident as observed and failed to communicate with R1's hospice care team of an event that may need further medical treatment of R1. Interviews and records revealed R1 grimaced and exhibited pain with movement beginning August 13, 2020. No treatment was provided for R1's rib fractures which were only identified through post-mortem examination. The licensee's failure to seek timely medical care caused R1 pain and distress over the course of many days due to undiagnosed emerging medical condition.

At the time of the complaint visit on February 1, 2021, an immediate civil penalty in the amount of $500 was being assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that an additional civil penalty is warranted for serious bodily injury. Welfare and Institutions Code Section 15610.67 defines serious bodily injury as an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.

Today, 04/19/2023, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 in the amount of $10,000 for a violation that the Department constitutes as a serious bodily injury. However, since an immediate civil penalty of $500 was previously issued on February 1, 2021, the amount of the civil penalty issued today will be $9500.

A copy of the LIC 421D was given to Steven Silacci and originals were signed.

Exit interview conducted.  Appeal Rights provided.  A copy of the report issued.  Signature on these reports acknowledges receipt of these rights, found on page 2 of LIC 421D. 

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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