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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202597
Report Date: 02/01/2021
Date Signed: 02/03/2021 02:34:21 PM



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
09/11/2020 and conducted by Evaluator Gladys Kuizon
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20200911101126
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: 29DATE:
02/01/2021
UNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Steven SilacciTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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1. Facility staff did not observe changes in resident's health condition.
2. Facility did not seek timely medical treatment for resident after fall.
3. Facility did not report incident which threatened the health and safety of resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gladys Kuizon conducted a complaint tele-visit today and met with Executive Director Steven Silacci to deliver investigation findings.

On September 11, 2020, the Department received the above allegation against the facility and conducted an initial complaint investigation tele-visit on September 22, 2020 to observe residents and request facility records.

Based on report from complainant, on August 12, 2020, resident (R1) had a fall in the facility and facility staff did not report the incident to R1's medical team and R1's responsible party. Furthermore, facility staff did not properly observe R1 for injuries from the fall and did not seek timely medical treatment for R1's injury from the fall.

Continued, see LIC 9099-C, page 2 of 3.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
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 5
Control Number 26-AS-20200911101126
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: 02/01/2021
NARRATIVE
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The investigation revealed that on August 12, 2020, R1 was found by facility caregivers, S1 and S2, on the floor in R1's room. 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.

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, 15, and 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 Santa Cruz 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.

Continued, see LIC 9099-C, page 3 of 3.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 26-AS-20200911101126
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: 02/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/02/2021
Section Cited
CCR
87411
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PERSONNEL REQUIREMENTS - GENERAL (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Licensee to submit written plan of correction to CCLD by POC due date.

*An immediate civil penalty of $500 is being assessed today.
*An additional civil penalty of $10,000 is under review for violation resulting in Serious Injury.
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Based on investigation, 2 staff who were involved in the incident failed to provide the services necessary to meet resident’s needs, as two staff did not report resident’s fall to hospice agency, which effected medical attention resident received
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This is an amended report
Type A
02/02/2021
Section Cited
CCR
87466
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87466 OBSERVATION OF THE RESIDENT. The licensee shall ensure that residents are regularly observed for changes...When changes...are observed, the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician & the resident's responsible person...
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Licensee to submit written plan of correction to CCLD by POC due date.
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This requirement was not met as evidenced by: Based on investigation, staff failed to observe R1's bruise on hip and failed to report the fall of 08/12/20 to hospice agency and R1's responsible party resulting in R1 not receiving appropriate medical attention. This posed an immediate risk to the health & safety of R1.
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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: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20200911101126
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: 02/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/05/2021
Section Cited
CCR
87211
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87211 REPORTING REQUIREMENTS
(a)(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence...This requirement was not met as evidenced by:
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Licensee to submit written plan of correction to CCLD by POC due date
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Based on investigation, facility did not provide written report of 08/12/2020 incident where R1 was found on the floor by 2 facility staff to Community Care Licensing within 7 days of incident. This posed a potential risk to the health and safety of R1.
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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: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 26-AS-20200911101126
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: 02/01/2021
NARRATIVE
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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.

Based on interviews of facility staff, 2 staff have 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 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 Department has conducted an investigation of the above allegations. Based on observations, records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. Civil Penalty in the amount of $10,000 for violation Resulting to Serious Bodily Injury is pending review.

A non-compliance conference meeting will be scheduled.

Deficiencies were cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 9099-D. Report was discussed with Executive Director Silacci. A copy of this report and licensee's Appeal Rights forms were sent via email for signature.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Gladys KuizonTELEPHONE: (408) 834-2558
LICENSING EVALUATOR SIGNATURE:

DATE: 02/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5