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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 445202597
Report Date: 09/18/2020
Date Signed: 09/18/2020 03:46:38 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: DATE:
09/18/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Eric JensenTIME COMPLETED:
03:38 PM
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Licensing Program Analysts Ryker Heberle and Jackie Jin (LPAs) met with interim executive director Eric Jensen (IED) in order to conduct an unannounced case management tele-visit to review a self reported SOC 341 regarding resident on resident altercation.

LPAs asked IED to describe his interpretation of the event.

LPAs requested the following: care plans, 602s of residents in question, status check logs/progress notes, witness statements.

Additional staff will be interviewed.

This report was reviewed with IED Eric Jensen and an electronic copy was provided on 9/18/2020 to obtain a signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker HeberleTELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2020
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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