Inspection Reports for Westwind Memory Care
160 Jewell St, Santa Cruz, CA 95060, United States, CA, 95060
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated, indicating that many concerns raised were not supported by evidence. The most recent report from March 20, 2025, was a complaint investigation with no deficiencies cited and the allegation was unsubstantiated. However, earlier reports show some serious issues, including substantiated findings in 2021 and 2023 related to failure to observe and report resident falls and changes in condition, which resulted in a resident’s death and led to multiple citations and a civil penalty. Medication management and coordination with hospice care were also cited as deficient in late 2023 but were addressed afterward. The facility’s record shows improvement over time, with no deficiencies found in the most recent inspections and most complaints not substantiated.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
2.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
88% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 52
Capacity: 59
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff restricted a resident's airway causing the resident to lose consciousness on 01/08/2025.
Complaint Details
The complaint alleged that staff member S7 pinched resident R1's nose on 01/08/2025 causing R1 to lose consciousness. Investigations included interviews with 7 staff and 5 residents, review of R1's physician report and care plan, and an internal facility investigation. Conflicting statements and lack of evidence led to the conclusion that the allegation was unsubstantiated.
Findings
After interviewing staff and residents and reviewing records, the Department found insufficient evidence to substantiate the allegation that staff pinched the resident's nose causing loss of consciousness. The allegation was determined to be unsubstantiated and no deficiencies were cited.
Report Facts
Staff interviewed: 7
Residents interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Administrator | Facility administrator met during the investigation and reviewed the report |
| Marcella Tarin | Licensing Program Analyst | Investigator who conducted the complaint investigation |
| Jin Jackie | Licensing Program Manager | Manager overseeing the licensing program for this investigation |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint received on 2023-08-25 alleging that staff did not meet a resident's hygiene needs and did not give medication as prescribed.
Complaint Details
The complaint was unsubstantiated. Allegations included failure to meet resident hygiene needs and failure to administer medication as prescribed. Interviews and record reviews did not provide sufficient evidence to substantiate the allegations.
Findings
The investigation found that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred. Staff provided showers twice a week as required, and medications were administered as prescribed. No deficiencies were cited.
Report Facts
Facility capacity: 59
Number of medications reviewed for resident R1: 5
Number of medications without start dates for resident R1: 3
Number of medications reviewed for resident R2: 4
Number of medications reviewed for resident R3: 7
Number of medications without start dates for resident R3: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Steven Silacci | Administrator | Facility administrator met during the investigation and was involved in the report review |
Inspection Report
Annual Inspection
Census: 51
Capacity: 59
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with regulatory requirements for the facility.
Findings
The inspection found the facility to be well-maintained with no deficiencies cited. A technical violation was issued related to incomplete CPR/First Aid training documentation for two staff members, which the administrator committed to remedy by submitting training copies by 12/06/2024.
Report Facts
Staff records incomplete: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Administrator | Met during inspection and named in relation to staff training documentation issue |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff did not notify the responsible party of a resident's change in condition.
Complaint Details
The complaint alleged that the facility's nurse falsified resident's change in condition to increase care rates and that in-house mental assessments should only be conducted by a physician. The allegation was determined to be unsubstantiated.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during the investigation |
| Karen Travis | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that staff does not communicate with the authorized representative.
Complaint Details
The complaint alleged that staff member (S1) does not communicate with family members via in person, telephone, or email. Interviews with the Executive Director and staff member indicated communication does occur and there have been no changes to how staff update family members. The allegation was determined to be unsubstantiated.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation was unsubstantiated.
Report Facts
Facility capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations that the facility is not training staff and that facility staff are causing injury to residents through improper lifting techniques.
Complaint Details
The complaint was unsubstantiated based on the investigation findings and records review.
Findings
The investigation found that in-service training on Proper Body Mechanics – Transfers was conducted on 4/28/2022 and 7/20/2022 by a physical therapist. Although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during the investigation |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff are not properly trained to care for residents with memory issues.
Complaint Details
The complaint alleged that staff were not properly trained, not engaging with residents, and were often on their cellphones, leading to declining resident health. The allegation was determined to be unsubstantiated.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated. Observations during the visit showed residents were supervised and staff had received training on Dementia and Alzheimer's Disease.
Report Facts
Staff training sample size: 8
Facility capacity: 59
Resident census: 55
Complaint receipt date: Oct 1, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during investigation |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility did not ensure residents had access to assistive devices while in care, resulting in falls.
Complaint Details
The complaint was unsubstantiated based on interviews, records review, and lack of sufficient evidence to prove the alleged violation.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation occurred, and therefore the allegation was unsubstantiated. The facility has a fall prevention program in place, including constant status checks and adequate staffing.
Report Facts
Capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during the investigation and provided information about facility practices |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations including staff not safeguarding resident's personal items, not providing activities, and not responding timely to resident requests for assistance, as well as allegations of questionable death and medication mismanagement.
Complaint Details
The complaint investigation was unannounced and addressed allegations of staff not safeguarding resident's personal items, lack of activities, delayed response to assistance requests, questionable death, and medication mismanagement. The allegations were determined to be unsubstantiated or unfounded based on interviews, observations, and records review.
Findings
The investigation found insufficient evidence to substantiate the allegations regarding safeguarding personal items, provision of activities, and timely response to assistance requests, resulting in an unsubstantiated determination. The allegation of questionable death was unfounded based on records and interviews. The medication mismanagement allegation was also unfounded as records showed proper medication administration according to the service plan.
Report Facts
Facility capacity: 59
Resident census: 55
Complaint receipt date: Feb 23, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
| Jackie Jin | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 08/17/2022 regarding resident care plans, staff assessments, admission agreements, planned activities, and staff behavior posing risks to residents.
Complaint Details
The complaint investigation was unsubstantiated as there was insufficient evidence to prove the alleged violations regarding care plans, staff assessments, admission agreements, activities, and staff behavior.
Findings
Based on interviews and records review, the department determined that although the allegations may have happened or are valid, there was not a preponderance of evidence to prove the alleged violations occurred; therefore, the allegations were unsubstantiated.
Report Facts
Capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during the complaint investigation |
| Grace Donato | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to a complaint alleging that the facility did not follow COVID-19 protocols.
Complaint Details
The complaint alleged the facility failed to follow COVID-19 protocols, including not testing a resident with COVID-19 symptoms. The allegation was unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that staff provided emergency kits and PPE, and residents with COVID-19 were kept in their rooms with masks. Based on interviews and records, there was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Report Facts
Capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during the investigation |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Reviewed the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that facility staff were not following doctor's orders.
Complaint Details
The complaint alleged that facility staff were inconsistent in following through with doctor's orders, specifically that it took a long time for staff to log doctor's orders in the system and that Med Techs did not see the orders. The allegation was determined to be unsubstantiated.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation was unsubstantiated.
Report Facts
Capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during the investigation and provided statements regarding the handling of doctor's orders |
| Grace Donato | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 08/17/2021 regarding staff neglect, unqualified staff, and poor quality food at the facility.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff neglect, unqualified staff, and poor quality food. Interviews and evidence did not support the claims sufficiently to prove violations.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Interviews with facility staff indicated status checks and staff training were conducted, and food quality concerns were addressed as residents are on special diets. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during investigation and provided information on facility operations |
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation visit |
| Jackie Jin | Licensing Program Manager | Reviewed the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 59
Deficiencies: 0
Date: Sep 19, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to complaints received on 07/30/2021 regarding understaffing and a non-working alarm system to alert staff about dementia residents.
Complaint Details
The complaint investigation was triggered by allegations that the facility was understaffed and that the alarm system to alert staff about dementia residents was not working. The allegation of understaffing was unsubstantiated, and the alarm system allegation was unfounded.
Findings
The investigation found the allegation of understaffing unsubstantiated due to insufficient evidence, and the allegation regarding the alarm system was determined to be unfounded as the facility has no alarm system but uses delayed egress doors and care plans to address resident needs.
Report Facts
Capacity: 59
Census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during the complaint investigation and provided information regarding staffing and alarm system |
| Grace Donato | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 59
Deficiencies: 0
Date: Nov 8, 2023
Visit Reason
The inspection was conducted as an unannounced complaint investigation following allegations of inappropriate staff interactions in the presence of a resident and failure to report unusual incidents to a resident's representative.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with staff and review of records. Staff denied inappropriate interactions and failure to report incidents. Attempts to interview some staff were unsuccessful.
Findings
After multiple interviews with staff and administrators, no preponderance of evidence was found to substantiate the allegations. The complaint was determined to be unsubstantiated and no deficiencies were cited under California Code of Regulations Title 22.
Report Facts
Facility capacity: 59
Census: 49
Staff interviewed: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Steven Silacci | Administrator | Interviewed regarding allegations and staff interactions |
| Parvendar Kaur | Wellness Director | Met with during inspection and report review |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 59
Deficiencies: 2
Date: Oct 31, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-10-09 alleging mismanagement of residents' medications and failure to coordinate care with the hospice agency.
Complaint Details
The complaint was substantiated based on evidence that facility staff failed to administer medications properly, did not coordinate with hospice agencies as required, and left medications unsecured. Some allegations were found unfounded or unsubstantiated after review of records and interviews.
Findings
The investigation substantiated that the facility failed to secure medications properly and did not ensure staff contacted the hospice agency before administering comfort pack medications, violating hospice care plans. One allegation regarding failure to follow physician's orders was found unfounded, and another regarding hygiene needs was unsubstantiated due to insufficient evidence.
Deficiencies (2)
Licensee did not ensure that R2 did not have unsecured medication in R2’s living unit, posing an immediate safety risk.
Licensee did not ensure that staff followed R3’s hospice care plan by contacting R3’s hospice agency before administering comfort paks.
Report Facts
Capacity: 59
Census: 49
Deficiencies cited: 2
Plan of Correction Due Date: Due date for submitting plan of correction is 2023-11-01
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Steven Silacci | Administrator | Facility administrator met during the investigation and was involved in report review |
| Karen Travis | Administrator | Named as facility administrator in report header |
| Sarah Yip | Licensing Program Manager | Oversaw licensing program and signed report |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-09-30 alleging insufficient staff numbers or competency to meet residents' needs.
Complaint Details
The complaint alleged that staff were not sufficient in numbers or competency to meet resident's needs. The investigation included interviews with staff employed at the time of the complaint and review of relevant records. The complaint was determined to be unfounded.
Findings
Based on interviews with staff and review of records, including staff schedules and medication logs, the complaint allegation was found to be unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Facility capacity: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Marrufo | Licensing Program Analyst | Conducted the complaint investigation visit |
| Karen Travis | Administrator | Facility administrator at time of investigation |
| Steven Silacci | Met with Licensing Program Analyst during investigation | |
| Sarah Yip | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 3
Date: Apr 19, 2023
Visit Reason
The visit was a case management follow-up on substantiated allegations regarding neglect and lack of supervision resulting in a resident's death.
Complaint Details
The complaint investigation concluded that staff did not observe changes in the resident's health, failed to seek timely medical treatment after a fall, and did not report the incident. The allegations were substantiated.
Findings
The investigation substantiated that facility staff failed to observe and report a resident's fall and changes in condition, resulting in delayed medical treatment and the resident's death. The licensee was cited for multiple violations and assessed a civil penalty for serious bodily injury.
Deficiencies (3)
Failure of two staff members to provide services needed to address resident's needs.
Failure to observe and assess a bruise and fracture after resident's fall.
Failure to provide a written report documenting resident's fall within seven days.
Report Facts
Civil penalty amount: 9500
Civil penalty amount: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Administrator | Facility administrator met during the case management visit and received the civil penalty notice. |
| Ryker Heberle | Licensing Program Analyst | Conducted the case management visit and authored the report. |
| Sarah Yip | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Capacity: 59
Deficiencies: 0
Date: Aug 18, 2022
Visit Reason
The inspection visit was a Case Management - Legal/Non-compliance inspection to ensure that the facility is adhering to the Compliance Plan submitted after a Non-Compliance Conference held on 03/08/2021.
Findings
The Licensing Program Analyst observed compliance with the facility's compliance plan, including staff training and resident fall assessment protocols. No deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Ryker Heberle | Licensing Program Analyst | Conducted the Case Management - Legal/Non-compliance inspection visit. |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 3
Date: Mar 24, 2022
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including failure to monitor resident's condition, lack of personal care resulting in toe nail infection, failure to follow resident's care plan, and facility mold presence.
Complaint Details
Complaint investigation was substantiated based on preponderance of evidence. Allegations included failure to monitor resident's condition, lack of personal care, and failure to follow care plan. The mold allegation was unsubstantiated.
Findings
The investigation substantiated that the facility failed to monitor and report changes in a resident's condition, did not follow the resident's care plan, and failed to provide assistance with toe nail care, posing immediate risks to resident health and safety. The allegation of facility mold was unsubstantiated due to lack of evidence.
Deficiencies (3)
Facility did not report changes in condition to a resident's responsible party, posing immediate risk to health and safety.
Facility staff did not follow resident's care plan, resulting in development of multiple physical ailments and posing immediate risk to health and safety.
Facility did not assist resident with clipping of toe nails when assistance was needed, posing potential risk to health and safety.
Report Facts
Facility capacity: 59
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Sarah Yip | Licensing Program Manager | Oversaw complaint investigation |
| Steven Silacci | Administrator / Executive Director | Facility administrator met during investigation and exit interview |
Inspection Report
Annual Inspection
Capacity: 59
Deficiencies: 0
Date: Dec 14, 2021
Visit Reason
An unannounced annual inspection was conducted as a required 1-year visit to evaluate compliance with licensing regulations.
Findings
The facility was found to be clean, well maintained, and compliant with all regulations. No deficiencies were cited during the visit. Staff and residents were vaccinated, PPE supplies were adequate, and safety measures such as fire extinguisher inspections and emergency exit clearances were verified.
Report Facts
Food supply: 2
Food supply: 7
Water temperature: 118.8
PPE supply: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Administrator | Met with Licensing Program Analyst during inspection and reviewed report |
| Ryker Heberle | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Sarah Yip | Licensing Program Manager | Named in report header |
Inspection Report
Census: 43
Capacity: 59
Deficiencies: 0
Date: Jul 9, 2021
Visit Reason
The inspection visit was a Case Management - Legal/Non-compliance inspection to ensure the facility was adhering to the Compliance Plan submitted after a Non-Compliance Conference held on 03/08/2021.
Findings
The Licensing Program Analyst observed proper resident fall and assessment protocols being followed, reviewed staff training records which were in compliance with the facility's compliance plan, and conducted interviews with caregivers whose responses reflected adherence to the compliance plan.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Executive Director | Met with Licensing Program Analyst during inspection and exit interview. |
| Erik Cintoa | Memory Care Program Manager | Present during the meeting with Licensing Program Analyst. |
| Ryker Heberle | Licensing Program Analyst | Conducted the inspection visit. |
| Sarah Yip | Licensing Program Manager | Named in report header. |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 1
Date: Jul 9, 2021
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2020-09-10 regarding facility staff not keeping resident's records confidential.
Complaint Details
The complaint was substantiated based on records reviewed and interviews conducted. The allegation was that facility staff did not keep resident's records confidential. The previous administrator admitted the error.
Findings
The investigation found that facility staff had accidentally sent confidential information of an incorrect resident to an outside party, substantiating the allegation. Deficiencies were cited under California Code of Regulations Title 22.
Deficiencies (1)
87506(c) Resident Records - All information and records obtained from or regarding residents shall be confidential. This requirement was not met as evidenced by facility providing confidential resident information to outside party, posing a potential risk to resident health & safety.
Report Facts
Facility capacity: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryker Heberle | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Steven Silacci | Administrator | Met with Licensing Program Analyst during investigation and received report |
| Eric Jensen | Previous facility administrator who admitted to the confidentiality breach | |
| Sarah Yip | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 42
Capacity: 59
Deficiencies: 0
Date: Jun 25, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident sustaining a fracture due to a fall and the facility not reappraising the resident after falls, as well as allegations of insufficient staffing, improper staff training, and failure to provide the responsible party with a report of a resident's death.
Complaint Details
The complaint investigation was initiated based on allegations received on 09/28/2020. The investigation included interviews with staff, residents, family members, and a witness, as well as review of records such as charting notes, alarm logs, training transcripts, and staffing schedules. The allegations regarding resident falls were determined to be unfounded, and the staffing-related allegations were unsubstantiated.
Findings
The investigation found the allegations of resident injury and failure to reappraise after falls to be unfounded, with evidence showing the facility had fall prevention plans and alarms in place. Allegations related to staffing and training were unsubstantiated, with staff and family interviews indicating adequate staffing and training, and no preponderance of evidence to prove violations.
Report Facts
Resident falls: 9
Staff interviewed: 4
Residents interviewed: 6
Family members interviewed: 3
Caregivers scheduled: 4
Med Techs scheduled: 2
Med Techs scheduled: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marybeth Donovan | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Steven Silacci | Executive Director | Facility representative met during investigation and report review |
| Karen Travis | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Capacity: 59
Deficiencies: 0
Date: Mar 8, 2021
Visit Reason
The visit was a noncompliance meeting held to discuss a complaint substantiated on 2021-02-01 and to review cited deficiencies related to that complaint.
Complaint Details
The complaint was substantiated on 2021-02-01. The facility's appeal on citation 87411(a) was denied. The Vice President requested a revision of the citation to indicate the number of employees designated as incompetent, which was agreed upon and revised by Licensing.
Findings
No deficiencies were cited during this meeting. The facility representatives indicated that the cited deficiencies have been addressed with additional training and changes in reporting policy. A compliance plan was reviewed and measures have been taken as outlined.
Report Facts
Facility capacity: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Steven Silacci | Administrator | Facility representative involved in the noncompliance meeting |
| Parvinder Kaur | Wellness Director | Facility representative involved in the noncompliance meeting |
| Lance Leland | Vice President of Organizational Development | Facility representative involved in the noncompliance meeting |
| Sarah Yip | Licensing Program Manager | Licensing official involved in the noncompliance meeting |
| Ryker Heberle | Licensing Program Analyst | Licensing official involved in the noncompliance meeting |
| Vivien Helbling | Regional Manager | Licensing official involved in the noncompliance meeting |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 59
Deficiencies: 3
Date: Feb 1, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/11/2020 regarding failure to observe changes in a resident's health, failure to seek timely medical treatment after a fall, and failure to report an incident threatening resident safety.
Complaint Details
The complaint investigation was substantiated. Allegations included failure to observe changes in resident's health, failure to seek timely medical treatment after a fall, and failure to report an incident threatening resident safety. The resident was found on the floor on August 12, 2020, with injuries not properly addressed. An immediate civil penalty of $500 was assessed, with an additional $10,000 penalty pending review.
Findings
The investigation substantiated that on August 12, 2020, a resident (R1) was found on the floor and staff failed to report the incident to the resident's medical team and responsible party, did not properly observe the resident for injuries, and did not seek timely medical treatment. The resident later died, with autopsy revealing broken ribs consistent with the fall timeframe. Deficiencies were cited for failure to report incidents, failure to provide sufficient personnel, and failure to observe and report changes in the resident's condition.
Deficiencies (3)
Failure to submit a written report of the 08/12/2020 incident where resident was found on the floor within seven days, posing a risk to resident health and safety.
Failure of two staff to provide necessary services and report resident's fall to hospice agency, affecting medical attention received.
Failure to observe resident's bruise and report fall to hospice agency and responsible party, resulting in lack of appropriate medical attention and immediate risk to resident health and safety.
Report Facts
Capacity: 59
Census: 29
Civil penalty immediate: 500
Civil penalty pending: 10000
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gladys Kuizon | Licensing Program Analyst | Conducted complaint investigation and delivered findings |
| Steven Silacci | Executive Director | Met with Licensing Program Analyst to receive investigation findings |
| Karen Travis | Administrator | Facility administrator named in report header |
Report
December 15, 2025
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