445202597-6-25-2021-26-AS-KHOS-C69J5W-20210826064524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445202597
Report Date: 06/25/2021
Date Signed: 06/25/2021 10:32:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20200928153555

FACILITY NAME:	WESTWIND MEMORY CARE		FACILITY NUMBER:	445202597
ADMINISTRATOR:	KAREN TRAVIS		FACILITY TYPE:	740
ADDRESS:	160 JEWELL STREET		TELEPHONE:	(831) 421-9100
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	59	CENSUS: 42	DATE:	06/25/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Steven Silacci		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Resident sustained a fracture due to a fall
Facility not reappraising resident after falls

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the findings to the above allegations. LPA met with Steven Silacci Executive Director.

During the course of investigation, the Department interviewed three staff members.

Staff stated R1 has a history of falls, and the facility has a plan in place to prevent the those falls. R1 also had an alarm system for R1’s bed and chair which notifies the staff if R1 got up. Staff stated R1 was checked on a regular basis during their shift, and R1’s needs are met in regard to fall prevention.

The Department interviewed the Coroner’s office and deemed R1’s manner of death was an accident. The corner did not feel the facility staff “did anything wrong,” and the facility staff summoned for help immediately.

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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 4

Control Number 26-AS-20200928153555

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WESTWIND MEMORY CARE	FACILITY NUMBER: 445202597
	VISIT DATE: 06/25/2021

NARRATIVE

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The Department reviewed charting notes, alarm logs, and resident interim service plans. Charting notes documented that R1 had four unwitnessed falls and five witnessed falls. The alarm logs documented that the alarm was triggered on all unwitnessed falls in July 2020. Charting notes also documented R1’s most recent fall that occurred on 09/10/2020, two facility staff were present, and assisted R1 to the floor and called for help. R1 was reappraised on the following dates 07/08/2020, 07/17/2020, 07/19/2020, 07/23/2020, 07/26/2020, and 08/09/2020 for witnessed and unwitnessed falls.

The Department has investigated the above allegations, and based on interviews and record reviews, the Department has determined that the allegations were Unfounded, meaning that the allegations were false, could not have happened and/or are without reasonable basis.

This report was review with Steven Silacci Executive Director and a copy of this report provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/28/2020 and conducted by Evaluator Marybeth Donovan

COMPLAINT CONTROL NUMBER: 26-AS-20200928153555

FACILITY NAME:	WESTWIND MEMORY CARE		FACILITY NUMBER:	445202597
ADMINISTRATOR:	KAREN TRAVIS		FACILITY TYPE:	740
ADDRESS:	160 JEWELL STREET		TELEPHONE:	(831) 421-9100
CITY:	SANTA CRUZ	STATE: CA	ZIP CODE:	95060
CAPACITY:	59	CENSUS: 42	DATE:	06/25/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Steven Silaaci		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Insufficient staffing
Facility staff not trained properly
Facility did not provide responsible party with report of resident's death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Marybeth Donovan arrived unannounced to deliver the findings to the above allegations. LPA met with Steve Silacci Executive Director.

Between 06/11/2021-06/18/2021 at total of four staff were interviewed. 4 out of 4 staff stated the facility has enough staff to meet the residents’ needs. All staff stated they are trained in bed/monitor alarms, fall prevention, and change of condition. S2 stated R1 fell and was transferred to the hospital; R1 did not return to the facility. R1’s family notified the facility of R1’s death.

On 06/18/2021 a total of six residents were interviewed. 3 of 6 residents stated they are taken care of by staff. The remaining three residents did not respond to interview questions.

On 06/16/2021 a witness was interviewed. Witness did not recall a time the facility was short staffed. Witness also stated the facility staff is trained in fall prevention, bed alarms, and change of condition. Page 1 of 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 26-AS-20200928153555

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: WESTWIND MEMORY CARE	FACILITY NUMBER: 445202597
	VISIT DATE: 06/25/2021

NARRATIVE

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On 6/16/2021 witness stated the facility conducted an internal investigation regarding a fall incident and left a voicemail regarding the result of the internal investigation.

Between 06/18/2021-06/21/2021 a total of three family members were interviewed. 3 out of 3 family members stated they have no concern with staffing at the facility and are in daily communication with staff regarding their family member's condition.

On 09/30/2020 a virtual tour of the facility was conducted. On the first floor LPA observed 4 caregivers and 1 Med Tech and on the second floor LPA observed 3 caregivers and 1 Med Tech. Residents were observed engaged in activities and groomed.

Staffing schedule for the month of September 2020 was reviewed. A total of 4-8 caregivers and 2 Med Techs are scheduled to work the AM and PM shift and 4 caregivers and 1 Med Tech were scheduled to work the NOC shift. Training transcript for 2017-2020 was reviewed. Staff training shows the staff are trained in the following areas: Alzheimer's Disease and Related Disorders: Medical Care, ADL Care of the Cognitively Impaired, Alzheimer's Disease and Related Disorders: Psychosocial Care, Alzheimer's Disease and Related Disorders: Behavior and ADL Management, Preventing Slips, Trips and Falls, Understanding Falls.

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

This report was review with Steven Silacci Executive Director and a copy of this report provided.

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SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth Donovan	TELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC9099 (FAS) - (06/04)

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