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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 445202597
Report Date: 07/09/2021
Date Signed: 07/09/2021 11:02:52 AM

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
09/10/2020 and conducted by Evaluator Ryker Heberle
COMPLAINT CONTROL NUMBER: 26-AS-20200910092635
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:
07/09/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Steven SilacciTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff did not keep resident's records confidential
INVESTIGATION FINDINGS:
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Licesnsing Program Analyst (LPA) Ryker Heberle conducted an unannounced complaint investigation visit and met with the Administrator Steven Silacci (Admin) to deliver the findings. On 9/17/2020, LPA received proof of documents distributed pertaining to another resident which were not requested from the facility. During an interview on 9/21/2020, previous facility administrator Eric Jensen admitted that facility staff had accidentally sent confidential information of incorrect resident to the requester.

The Department has conducted an investigation of the above allegation. Based on records reviewed and interviews conducted, the preponderance of evidence standard has been met. Therefore, the Department found the above allegations to be SUBSTANTIATED. Deficiencies cited per the California Code of Regulations Title 22, see attached 9099D. This report was reviewed with Administrator Steven Silacci and an copy was provided on 7/09/2021.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
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 2
Control Number 26-AS-20200910092635
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: 07/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/16/2021
Section Cited
CCR
87506(c)
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87506(c) Resident Records - All information and records obtained from or regarding residents shall be confidential. This requirement was not met as evidenced by:
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Facility agreed to provide in-service training with med techs and managers to ensure best practices in document distribution are met while stressing the importance of confidentiality and adherance to HIPAA and provide proof of completion to LPA by POC due date.
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Based on records review and interviews, facility provided confidential resident information to outside party. This posed a potential risk to resident health & safety
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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.
SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: Ryker Heberle
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2