Westwind Memory Care

Allegation investigated: Staff did not prevent resident from physically abusing residents resulting in injuries Staff inappropriately admitted a resident who doesn't meet the criteria of care for the facility

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to deliver the findings of the complaint investigation that was received by the Department on 07/08/2025. LPA met with Executive Director (ED) Steven Silacci. LPA stated the purpose of the visit. On 7/14/2025, the Department conducted the initial complaint investigation visit to the facility and interviewed 10 Staff (S1 to S10) and 4 Residents (R1 to R4). It was alleged that Resident R1 hit Resident R3’s glasses off his/her face in late June 2025. On 7/14/2025 LPA interviewed 4 Residents (R1 to R4). 3 Out of 4 residents stated he/she has not observed or has been involved in any altercations with another resident. Page 1 of 2 Unfounded R1 states staff has accused him/her of grabbing another resident but was unable to provide any factual information regarding this alleged incident. R3 states he/she has not been hit by another resident. R2 did not provide any additional information regarding this incident. On 12/2/2025 LPA interviewed Family Member 1 (FM1). FM1 states he/she has no concerns about the care his/her loved ones are receiving at the facility. FM1 states he/she is not aware of any incidents at the facility involving her loved ones. LPA interviewed Executive Director (ED). ED states he is not aware of any physical altercations between residents in May 2025 and June 2025. There were no reported incidents of any physical altercations between residents reported to the Department for the months of May 2025 and June 2025. LPA reviewed facility communications logs for June 2025 and July 2025. There were no incidents of altercations between residents. Staff inappropriately admitted a resident who doesn't meet the criteria of care for the facility. It has been alleged that the facility is “strictly for dementia residents only” and the facility admitted a resident who did not have dementia. Based on review of the facility program plan, “Westwind Memory Care is a residential facility for the elderly operating 24 hours a day, 7 days per week, caring for clients 60 years of age and over in Santa Cruz, California…It is the goal of the community to provide supportive care to seniors.” This agency has investigated the complaint. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. Page 2 of 2 END OF REPORT LPA interviewed 4 Residents (R1 to R4). 2 out 4 Residents stated they have not been left in a soiled diaper for an extended period of time. R1 declined to be interviewed and R2 did not provide additional information. On 12/2/2025 LPA interviewed Family Member 1 (FM1). FM1 states he/she has no concerns about the care his/her loved ones are received at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Dec 15, 2025 · control 26-AS-20250708105358

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin arrived unannounced to conduct the facility's required 1 year inspection. LPA met with Executive Director (ED) Steven Silacci. LPA stated the purpose of the visit. LPA toured the interior and exterior of the facility with ED to include but not limited to the kitchen, resident rooms, dining room, and resident bathrooms. The facility was observed to be clean, safe, sanitary and in good repair. All exit and passageways were free and clear of obstruction. LPA observed facility doors on the first and second floor are keypad alarmed. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. LPA observed the refrigerator temperature at 35 F and Freezer at -10 F. LPA observed the medication storage area, knives storage area, and cleaning product storage area as locked and inaccessible to residents in care. The facility fire system was inspected by a third party vendor on 12/10/2025 and passed inspection. Fire extinguishers were last serviced on 10/17/2025. LPA reviewed the facility first aid kit, and it was observed to be complete. The facility emergency drill log was reviewed. The facility's last drill was conducted on 11/10/2025. Page 1 of 2 LPA toured 5 resident bedrooms. All 4 resident rooms have a bed, functioning lights, dresser/table, bedding and space for personal belongings. LPA toured 5 bathrooms. All 5 bathrooms had hand soap, paper towels, functioning lights, and covered trash bins. LPA measured water temperature with a range of 108.5 F to 115.5 F. LPA reviewed 3 resident records. LPA reviewed 3 resident’s Centrally Stored Medication and Destruction Records (CSMDR’s). LPA reviewed 3 staff records. No deficiencies were cited during today's visit per California Code of Regulations Title 22. An exit interview was conducted with Executive Director (ED) Steven Silacci and a signed copy of this report was provided. Page 2 of 2 END OF REPORTthe state’s words, verbatim · CDSS document, Dec 15, 2025

Allegation investigated: Staff restricted resident's airway, resulting in resident losing consciousness

On 01/9/2025 the Department received a complaint alleging that staff restricted resident’s airway causing the resident to lose consciousness on 1/8/2025. It has been alleged that staff S7 pinched resident R1’s nose causing R1 to lose consciousness. On 1/10/2025, the Department investigated the alleged incident that occurred on 1/8/2025 wherein the incident involves a resident (referred to as R1), who was in an agitated state. R1 was having behaviors, while holding a statue of a crane, while screaming, yelling and moving toward staff in an aggressive manner at approximately 7AM. Staff members (referred to as S1 to S7) were able to intervene and deescalate situation and eventually, R1 remained calm and able to redirect by staff. Page 1 of 3 Unsubstantiated During the Department’s investigation, on 1/21/2025 and 1/23/2025, 7 staff were interviewed. 5 Out of 7 staff did not observe R1’s nose pinched by S7 on 1/8/2025 when R1 was having behaviors while 2 Out of 7 staff state they observed R1’s nose being pinched by staff S7. 7 Out of 7 staff state R1 was having behaviors on 1/8/2025, where R1 was in an agitated state, screaming, yelling, and moving toward staff. These two staff members who observed the alleged abuse by a staff pinching R1’s nose also noted it caused R1 to lose consciousness. S7 stated on 1/8/2025 he/she was in the hallways when he/she observed R1 agitated and being aggressive with staff. S7 states he/she went over to help de-escalate and calm R1 by speaking calmly to R1 and only touching his/her shoulders to re-direct. S7 states it took 30 seconds to calm down R1. S7 denies pinching R1’s nose. On 1/18/2025 and 2/18/2025, the Department interviewed 5 residents (referred as R1 to R5) during the investigation. 4 Out of 5 residents state they did not observe a staff pinch R1’s nose. 1 Out of 5 residents (R1) stated his/her nose was “grabbed” by a staff described as a “heavy girl” but could not identify any of the staff involved in the incident. R1 states the incident occurred three weeks ago. On 1/23/2025, the Department conducted an interview with ADM regarding the allegation. ADM states on 1/13/2025, an internal investigation was conducted by the facility. ADM states he/she conducted interviews with 7 staff S1 to S7 wherein staff recollection of the incident made inconsistent statements. Due to insufficient evidence, the facility was unable to substantiate the allegation that R1’s nose was pinched by a staff on 1/8/2025. Page 2 of 3 The Department obtained R1’s Physician’s report and Appraisal Needs and Services Plan (ANS). During a review of R1’s Physician’s Report dated 12/20/2024, R1’s mental condition is associated with confusion, disorientation, and is sometimes able to follow directions and has major neurocognitive disorder. R1’s ANS dated 12/24/2024 states R1 requires “ongoing assistance with care…with speech, functional and behavioral impairments due to disoriented to person/time/place….” and R1’s needs moderate assist with “interventions and care coordination to de-escalate negative behaviors.” Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are UNSUBSTANTIATED. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Administrator Steven Silacci and a copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 20, 2025 · control 26-AS-20250109132853

Allegation investigated: Staff did not meet resident's hygiene needs Staff did not give resident medication as prescribed

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Steven Silacci, Administrator. On 08/25/2023, the Department received a complaint with the above allegations. On 09/01/2023, LPA Marrufo conducted an initial complaint investigation visit. The facility Resident Roster states resident R1 moved into the facility on 07/11/2023. LPA Marrufo obtained a copy of R1’s Service Plan. R1’s Service Plan states R1’s move-in date was 07/10/2023. R1’s Service Plan states R1 needs assistance with bathing two times per week. R1’s Service Plan states staff must monitor R1’s skin and provide hemorrhoid cream if R1 has skin irritation. See LIC9099-C pages for more information. Page 1 of 4. Unsubstantiated R1’s Medication Administration Record (MAR) indicates staff checked R1’s skin from 07/13/2023 to 07/17/2023 and found no issues. The next skin monitoring in R1’s MAR is recorded on 08/29/2023 to 08/31/2023. The AM entry for 08/29/2023 states that R1 has no skin issues. The PM entry for 08/29/2023 states that R1 does have skin issues. The entries for 08/30/2023 and 08/31/2023 state that R1 has skin issues. The entry in R1’s MAR for 09/01/2023 states R1 has skin issues. The 24-Hour Communication Logs from July 2023 state the following: R1 was observed to be confused on 07/13/2023, 07/16/2023, 07/18/2023, 07/26/2023, and 07/27/2023. On 07/27/2023, the 24-Hour Communication Log states R1 refused to shower and R1’s rectal area was observed to be red and painful. The 24-Hour Communication Log from 07/31/2023 states R1 was observed to be hoarding dirty underwear and didn't want to wash them or change clothes because R1 believed that R1 would be leaving the facility soon. The ADL (Activities of Daily Living) Resident Refusal Form from 07/13/2023 states that R1 refused an ADL on that day; however, the form does not specify the specific ADL that R1 refused. The form states that staff provided three interventions and R1 refused all the interventions. The form states that undergarment/brief change, peri care, clothing change, and face/ear wash were completed as alternate hygiene care for R1. The 24-Hour Communication Logs from August 2023 indicate staff provided R1 with a shower on the following dates: 08/02/2023 (time not indicated), 08/09/2023 PM, 08/16/2023 PM (R1 refused), 08/17/2023 PM, 08/20/2023 AM (R1 refused), 08/20/2023 PM, 08/23/2023 AM, and 08/27/2023 AM. R1’s Chart Note from 08/16/2023 9:38 PM states that R1 refused three staff prompts for a shower. On 01/07/2024, LPA Marrufo interviewed staff S2-S5. S2-S4 stated that staff would provide showers to R1 twice a week. S5 stated that R1 would often refuse staff’s encouragement to take showers. Page 2 of 4. LPA Marrufo received an email from R1’s Responsible Person on 08/31/2023 7:26 PM. R1’s Responsible Person stated in the email that staff could not provide the ointment that R1’s Responsible Person provided to R1 since the ointment was not prescribed. R1’s Responsible Person states staff told R1’s Responsible Person that they provided a barrier cream instead and R1’s rash was now gone. R1’s Physician’s Orders states that on 08/23/2023, R1 was prescribed an ointment as a PRN for a rash diagnosis. R1’s Medication Administration Record (MAR) indicates staff checked R1’s skin from 07/13/2023 to 07/17/2023 and found no issues. R1’s MAR indicates there was no entry into the Skin Issues log but staff nonetheless applied R1’s prescribed ointment for skin rashes on the following dates: 08/23/2023, 08/24/2023, 08/25/2023, and 08/27/2023. R1’s MAR indicates staff recorded skin issues with R1 and applied R1’s prescribed ointment for skin rashes on the following dates: 08/292023, 08/30/2023, 08/31/2023, and 09/01/2023. LPA Marrufo did not observe any other dates in R1’s MAR that indicated R1 was observed to have had skin issues. On 09/01/2023, LPA Marrufo conducted a medication review of residents R1-R3 with staff S1. During medication review, LPA Marrufo observed 5 medications belonging to R1. 3 out of 5 of R1’s reviewed medications did not contain a start date on the medication container. LPA reviewed 4 of R2’s medications, and all 4 medications had a start date. LPA reviewed 7 of R3’s medications. 2 out of 7 reviewed medications belonging to R3 did not have a start date on the medication container. S1 stated that typically medications have stickers with start dates on the medication container. S1 stated to not be able to say why some of the medications were missing start dates. During interview on 01/07/2025, S6 stated that when a resident is newly admitted to the facility and the resident's family brings medications with the resident, the medications often do not have start dates on them because there is no way to verify the actual start dates of the medications. S6 stated to be certain that this was the case with R1's medications and possibly other resident medications. S6 stated that medications of new residents are counted when they first arrive. Page 3 of 4. On 01/07/2024, LPA Marrufo interviewed staff S2-S5. S2-S5 stated to have never observed a time when R1’s prescribed rash ointment was not given as prescribed. S2 stated to have never observed a time when R1 was not given medications as prescribed. S3-S5 stated to not have any information as to whether or not R1 was ever not given medications as prescribed. An Advisory Note has been issued. See LIC9102 for more information. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22 This report was reviewed with Administrator Steven Silacci and a copy of this report was provided. Page 4 of 4. END REPORTthe state’s words, verbatim · CDSS document, Jan 7, 2025 · control 26-AS-20230825133741

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Marcella Tarin conducted an unannounced annual inspection and met with Administrator (ADM) Steven Silacci. LPA toured the interior (1st and 2nd floor) and exterior of the facility with the ADM to include the resident activity areas, dining rooms, kitchen, resident bedrooms, bathrooms, and exterior. Facility temperature maintained at 72 degrees F. Facility staff are fingerprint cleared and associated to facility. All emergency exits were observed to be clear of obstruction. LPA toured the kitchen area and observed a perishable food supply of at least two days and a non-perishable food supply of at least seven days. Refrigerator temperature maintained at 35 degrees F and freezer maintained at -10 degrees F. No toxins, chemicals or items that can pose a danger to residents observed. The facility was equipped with smoke and carbon monoxide detectors. Fire extinguishers were last serviced on 8/22/2024. LPA observed the facility first aid kit and it was observed to be complete. The facility fire/earthquake drill log was reviewed and drills are being conducted quarterly. The last fire drill was conducted on 11/25/2024. Facility has emergency disaster plan. LPA Tarin toured 6 resident bedrooms. LPA toured 3 resident bedrooms on the 1st floor and 3 resident bedrooms on the 2nd floor. 6 out of 6 resident bedrooms had functioning lights, storage space for personal belongings, clean bedding, and a dresser/table. LPA measured hot water temperature, with a range of 108.3 to 119 degrees F for 6 out of 6 resident bathrooms. LPA reviewed 6 residents electronic Centrally Stored Medication and Destruction Records (CSMDR). LPA observed 6 out of 6 electronic CSMDRs are complete with all medications accounted and documented. LPA observed the medication storage area was locked and inaccessible to residents in care. See LIC809C LPA reviewed 6 out of 6 resident records. LPA observed 6 out of 6 resident records as complete to include a medical assessment, TB result, updated appraisal/needs and services plan, identification and emergency contact information, personal rights, and consent forms. LPA reviewed 6 out of 6 staff records. LPA observed 4 out of 6 records as complete to include fingerprint clearance, health screening, TB result, personnel record, and annual training . Staff (S4) and (S5) records were observed as incomplete. S4 and S5 files did not contain current CPR/First Aid training. ADM states both S4 and S5 completed the CPR/First Aid training, but the facility did not have the documentation in S4 and S5 staff files. ADM stated he would obtain copies of the CPR/First Aid training and submit copies to LPA by 12/06/2024. No deficiencies were cited today per California Code of Regulations, Title 22. A Technical Violation was issued. An exit interview was conducted with Administrator Steven Silacci. A copy of this report was provided.the state’s words, verbatim · CDSS document, Dec 3, 2024

Allegation investigated: Staff did not notify responsible party of resident's change in condition

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of staff did not notify responsible party of resident's change in condition, Reporting Party (RP) states that the facility's Nurse (S1), is falsifying resident's change in condition as an excuse to increase resident's rates for care. RP states that S1 completes the facility's in-house mental assessments for residents that have dementia. RP does not agree with the facility staff conducting in-house assessments regarding a resident's change in condition. RP states that resident assessments should only be conducted by a physician. Unsubstantiated According to Title 22 Regulation 87466 Observation of the Resident, The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. With a resident with Dementia, an annual medical check up by a residents physician is required. Facility is also allowed to to assessments and reassessments whenever there is a change in condition. LPA was also able to obtain emails showing proof that the facility gets in touch with the residents responsible parties/family members. Based on records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20210430142806

Allegation investigated: Facility staff not following doctor's orders

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of Facility staff not following doctor's orders, Reporting Party (RP) stated that the facility is not consistent with following through with doctor's orders. When the facility receives a doctor's order from the physician, it takes a long time for staff to log the information in the facility's system, and the Med Tech does not see the doctor's order for the resident. LPA interviewed ED and it was stated that once the facility receives the doctors orders through fax. It is immediately updated in the system. Medication rooms has the fax machine. Memory Care Manager, Med Techs, Directors are able to update the system once the orders are received. LPA is not able to reach RP due to the number provided was a wrong number. Based on interviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviwed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20210623095010

Allegation investigated: Facility is understaffed

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of Facility is understaffed, RP states there is only one night staff overseeing the whole facility of 30 residents. There have been no accidents or injuries yet. RP states nighttime is the highest risk for residents to get out of bed and possibly fall. According to the interview with ED, Private sitters are suggested when needed. Staffing right now is 4 caregivers per floor with 1 med tech for each floor for 26 residents. NOC shift has 2 caregivers per floor and 1 med tech for all floors. Based on interviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20210730131535

Allegation investigated: Staff neglected resident(s) in care. Staff not qualified. Facility is not providing quality food to residents.

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of Staff neglected resident(s) in care, RP stated that a caregiver reported to RP that he/she has witnessed that between 7am – 8am on 8/16/2021, a resident was found sleeping on the bedroom floor, with a blanket and a pillow, with clothes on. RP and caregiver are concerned because the last person who saw this resident was a staff member somewhere between 11 pm – midnight the evening before. LPA interviewed ED and WD (Wellness Director) both mentioned that status checks are done depending on the care plan of the residents. Unsubstantiated Regarding the allegation of Staff not qualified, RP stated that this caregiver told her that the staff are not trained properly, and get no training at the facility, and "they don't really know what they are doing". RP added that the facility claims that staff have been trained properly, but they are not - and that many of the staff are clueless, burned out (facility works them a lot of hours daily) and this lack of training makes RP concerned for the welfare of the residents. According to the interview with the ED and WD, they stated that they had recently (8/11/2022 interview) initiated many training for staff included training on dementia care and how to properly lift residents safely. There were also no staff members have ever verbalized concern about the frequency or quality of training. Nor any family members in recent memory. Regarding the allegation of Facility is not providing quality food to residents, RP stated that the food being served to the residents "is a huge problem", and RP works with many facilities in the area and "it's worse here than any other facility I have seen". In addition, the caregiver told RP that the food is horrible, and that "I don't even recognize what it is." During the interview, the ED mentioned that most of the residents are on a special diet like a mechanical soft diet. The food would obviously not look the same as regular food serve. Based on interviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20210817083410

Allegation investigated: Staff are not properly trained.

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of staff are not properly trained, RP stated that this facility has staff who lack training to care for residents with memory issues. RP states, staff are not engaging with residents as far as moving them around. RP states, staff are always on their cellphones and feels when the residents are not getting the attention needed, the resident’s health is declining. LPA Nguyen visited the facility on 10/11/2021 and it was observed that all staff were wearing masks. That physical distancing was encouraged among residents. All residents appeared clean and do not appear to be in any form of physical distress. Unsubstantiated Additionally, the following was observed during tour: 1 resident was out taking a walk with a staff. 18 residents was watching TV in living area after having lunch with 4 staff supervising. 4 residents was having lunch in dining with 1 staff supervising. 1 resident was at the salon with staff. 2 staff was helping resident with ADL. 3 residents was waiting for family members in the lounge/ receptionist area. 1 resident was out for a walk with family member. Based on records review, a random sampling of 8 staff members were chosen, who worked between 3/2021 – 11/2022. All these staff members received training through Relias regarding Dementia & Alzheimer’s Disease. Based on interviews, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20211001164057

Allegation investigated: Staff does not communicate with authorized representative.

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of Staff does not communicate with authorized representative. Reporting Party (RP) stated that the staff memner (S1) does not communicate with family members via in person, telephone or email. LPA Heberle was able to interview ED & S1 and stated that there is communication between the residents responsible party. Both stated that There has been no changes to how staff update family members with changes in condition. Facility continues to have sit down meetings with families. ED also mentioned that Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20220105114249

Allegation investigated: Facility is not training staff Facility staff are causing injury to residents through impoper lifting techniques

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation that Facility is not training staff & facility staff are causing injury to residents through improper lifting techniques, Reporting Party (RP) stated that the staff are not being trained how to lift the residents from the chairs and the beds and wheelchairs, and also how to sit them down. If they do train them, they are not watching to see. I think there is failure to train and check off on the staff. Based on records review, an in-service training was conducted regarding Proper Body Mechanics – Transfers held on 4/28/2022 and 7/20/2022 which was conducted by a physical therapist. Based on these records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20220811140211

Allegation investigated: Residents care plans are not regularly updated Staff are not conducting accurate assessments for the residents Staff are not abiding to the admission agreement Staff do not have planned activities fro the residents Staff behavior poses as a risk to residents while in care

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegations Residents care plans are not regularly updated, Staff are not abiding by admission agreements, Staff do not have planned activities that are suitable to resident needs, Staff are not being properly trained for residents with dementia, Staff are not providing adequate food service to the residents. LPA Donato tried to call RP, but RP is no longer available to be able to get more information on these allegations. LPA Heberle was able to interview the Activities Director (AD), and it was stated that there are 3 activities per day, one in the morning, afternoon, and evening. AD plans additional activities based off of personal likes profiles that are developed. AD puts on different music and shows based off of what residents requests. In the morning they do exercises, but walks happen all the time. The first floor especially does a lot of walks because of the garden. Residents on the second floor often don't come down. Residents on the second floor are content to simply walk up and down the halls, which activities staff assists them with. Unsubstantiated Another staff member (S2) mentioned that training is pretty good, it would be more helpful if they had trainings on specific residents, rather than general training. Staffing levels are good, it's a challenge during call offs but there are typically 3 to 4 RAs per floor. Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20220817163154

Allegation investigated: Facility did not ensure that residents had access to assistive devices while in care resulting in falls.

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of facility did not ensure that residents had access to assistive devices while in care resulting in falls, Reporting Party (RP) stated that Assistive devices not in place per care plan, or implemented timely, both resulting in resident falls. LPA interviewed the ED and it was mentioned that the facility has no bed alarms. All the residents needs are addressed in the care plan like constant status checks. LPA Heberle also interviewed 2 staff members. S1 stated that there's 4 staff on 2nd floor per shift and about 3 on the first floor per shift. Thinks that staff is very capable on how to lift and they always have enough people to assist residents as needed. Has definitely received adequate training, receives training that they are tested on monthly. Unsubstantiated Based on records review, according to a service plan on one of the residents (R1), there is an Increased Risk for Fall so staff to provide assistance in the case of a fall. Fall prevention program is in place. Meaning, as explained by ED and WD (Wellness Director), constant status checks and facility has enough staff to continuously do check on resident. Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20220823091905

Allegation investigated: Facility did not follow COVID-19 protocols.

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of Facility did not follow COVID-19 protocols, RP stated that they received a report from an unnamed caller that they upset at the facility's lack of response to a covid infection in the building. Caller states that the Health Services Director (HSD) was aware of a covid infection in the building but said they weren’t going to test the resident because they did not have symptoms. Caller reports that now staff have covid. LPA interviewed staff members and 4 out 4 stated that there are emergency kits placed outside the residents rooms who had covid and PPEs are provided to staff. S4 mentioned that they self test if they have symptoms and can't come back until they have a negative test. Unsubstantiated S2 also stated that they try to keep the residents who have covid in their rooms as much as possible and have residents wear mask. Based on records review, according to PIN 23-02-ASC, a guidance released by Licensing to facilities, facilities are recommended to test but not required. This PIN was released on February 9, 2023. Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20230216112023

Allegation investigated: Staff did not safeguard resident's personal items Staff did not provide resident with activities Staff did not respond to resident request for assistance in a timely manner

On 9/19/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director, Steven Silacci and explained the purpose of today's visit. Regarding the allegation of staff did not safeguard resident's personal items, Reporting Party (RP) stated that R1s laundry was not individually washed as promised. RP states that other residents wore R1s clothing and were found rummaging in R1s belongings. LPA interviewed ED and mentioned that laundry is done seprately for each resident. Facility is a memory care facility, we are not able to lock the doors of residents bedrooms. Some residents wander around other residents rooms so we try to redirect them. Unsubstantiated Regarding the allegation of Staff did not provide resident with activities, RP states that staff left the residents in front of a tv every day and did not provide them with activities. As ED stated, the facility has an activity coordinator, while we highly encourage residents to participate in the activities provided, it is still the residents right to not join if they don’t want to participate. LPA also observed residents participating in balloon play during the visit. Based on records review the facility has different scheduled activities per day like exercises, pet therapies, chair dancing, baking, walking and strolling and more. Regarding the allegation of Staff did not respond to resident request for assistance in a timely manner, RP states that while visiting she observed residents yelling for assistance and staff never came. The RP notes that residents do not have call buttons in their rooms, so it takes a long time for staff to notice when a resident needs assistance if they notice at all. ED and WD stated that the staff wont be able to address all the needs at once but they strive to help and assist residents as fast as they can Based on interviews and records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided. According to ED, R1 hasn’t returned and actually moved out on 2/1/2022, which is also noted in the progress notes. Regarding the allegation of staff mismanaged resident medications, RP states that staff gave R1 "anti-psychotic" medications to make R1 sleep, but never obtain consent prior to giving the medication. According to records review, it is stated in R1s service plan that he/she is to be given a Psychotropic Drug like Antidepressants. Also on the records, R1 was only to be given a PRN medication to help sleep but only during bedtime. Based on interviews and observations, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Sep 19, 2024 · control 26-AS-20220223151643

Allegation investigated: Facility staff were having inappropriate interactions in the presence of a resident. Staff did not report unusual incident to a resident's representative.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Parvendar Kaur, Wellness Director. On 08/15/2023, the Department received a complaint investigation with the above allegations. LPA Marrufo conducted an initial complaint investigation visit on 08/23/2023 and conducted an additional visit on 10/03/2023. During visit on 08/23/2023, LPA Marrufo interviewed 16 facility staff. 16 out of 16 staff stated to have not observed any inappropriate interactions On 08/23/2023, LPA Marrufo made a telephone call to staff S1 to conduct an interview, but S1 refused to be interviewed. See LIC9099-C for more information. Page 1 of 2. Unsubstantiated On 10/20/2023, LPA Marrufo conducted a telephone interview with staff S2. During interview, S2 denied having any inappropriate interactions with another staff, including staff S3. LPA Marrufo attempted to conduct telephone interviews with S3 on 08/15/2023, 10/20/2023, and 11/07/2023, but was not able to reach S3. During interview on 08/23/2023, Administrator Silacci stated to have interviewed S2 and S3 separately and both S2 and S3 denied having had any inappropriate interactions in the presence of a resident or in the facility. During interview on 10/03/2023, Administrator Silacci stated to have asked S2 and S3 what they were doing in a resident room together, and S2 and S3 stated to have been assisting residents together in the residents’ rooms. Based on information from interviews conducted with staff, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated. No Deficiencies were cited under California Code of Regulations Title 22. This report was reviewed with Parvendar Kaur, Wellness Director, and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Nov 8, 2023 · control 26-AS-20230815113903

Allegation investigated: Facility mismanaged residents medications. Facility did not coordinate care with hospice agency.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Steven Silacci, Administrator. The Department received a complaint on 10/09/2020. The complaint made the following allegations: facility staff were not administering resident R1’s new order for Naproxen and order for Lorazepam; Resident R2 was found with morphine medication tablets on R2’s pillow and R2’s liquid Roxanol order had not been started; facility staff administered R3’s comfort pack medications without receiving an order from R3’s hospice agency; facility staff were unable to explain to R2’s hospice agency how much of the PRN Phenobarbital orders staff had administered to R2, causing difficulty for the hospice agency to appropriately titrate scheduled medication; facility staff did not conduct regular checks on R4 to ensure R4 was not ingesting and covered with R4’s own feces. See LIC9099-C for more information. Page 1 of 3. Substantiated The Department conducted an initial complaint visit on 10/19/2020 and conducted additional complaint investigation visits on 07/09/2021, 08/23/2023, 10/03/2023, and 10/24/2023. R2’s Charting Notes from 07/11/2020 at 6:47 PM states, “Family member found medication of resident on the floor, family member asked if it could be crushed so it could be administered, explained it could not due to label specifications/instructions.” R3’s Hospice Team Care Plan indicates that R3 had a comfort pak that included orders to give 0.25 ml of Morphine Sulfate, Lorazepam 0.5 mg tablet every 6 hours for PRN for anxiety or agitation, and to call the hospice agency to initiate any comfort pak medication. R3’s Charting Notes entry from 01/08/2020 at 5:52 AM indicate that staff administered PRN of morphine to R3; the entry does not indicate if hospice was notified. R3’s Charting Notes from 01/08/2020 at 3:00 PM states, “[R3’s spouse] requests that we give small (0.25 ML) dose of morphine during waking hours and only use (0.5ML) dose during the night.” R3’s Charting Notes entry from 10/12/2020 2:00 PM stated R3 was given 0.25 ML of morphine and 0.5 MG of Lorazepam, but there is no statement about if the hospice agency was contacted prior to administering the comfort pak medications. On 10/24/2023, LPA Marrufo interviewed facility staff S1. During interview, S1 stated that staff are supposed to log that they have contacted the hospice care agency prior to initiating a comfort pak. S1 stated staff are not to take medication orders from families. On 10/03/2023, LPA Marrufo interviewed facility staff S2. During interview, S2 stated to have the job role as medication technician at the facility and was trained for almost two months in that role. S2 stated that before administering comfort paks, facility staff have to call the hospice agency and let the hospice agency know the resident’s condition. S2 stated the hospice agency will then let the staff know if the resident can use the comfort pak, which medication, and the dosage. S2 stated staff are supposed to chart the phone call with hospice care in the Medication Administration Record (MAR) in the resident’s chart notes. S2 stated if a family member asked if a resident could receive a comfort pak, staff would still need to contact the hospice agency first before administering the comfort pak. Page 2 of 3. LPA Marrufo obtained copies of R5 and R6s Charting Notes. The Charting Notes for R5 from 07/18/2023 and for R6 on 09/09/2023 both indicate that staff contacted the hospice agency prior to administering comfort paks. R2’s Charting Notes from 07/09/2020 at 5:34 AM states, “Before 3:30 am [R2] was pacing the hallways and a little agitated. Gave PRN.” The Charting Notes entry does not indicate which PRN was administered to R2 and if the hospice agency was notified. Based on records review and interviews, there is preponderance of evidence to prove the alleged violations did occur. Therefore, the allegations are substantiated. See 9099-D for deficiencies cited per the California Code of Regulations, Title 22. This report was reviewed with Steven Silacci and a copy of the report and appeal rights were provided. Page 3 of 3. END REPORT S3 stated staff would also divert R4’s attention with various activities to prevent R4’s behaviors with feces. S3 stated to not remember if there was a time when facility staff were told R4 had ingested feces but staff did not respond. Administrator Steven Silacci stated S3 is the only staff at the facility who worked with R4 and is still employed at the facility. Based on information from interviews conducted with staff, and records reviewed, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is unsubstantiated. No Deficiencies cited under California Code of Regulations Title 22 This report was reviewed with Steven Silacci and a copy of this report was provided. Page 2 of 2. END REPORTthe state’s words, verbatim · CDSS document, Oct 31, 2023 · control 26-AS-20201009161515

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(B) · Plan of correction due date: Nov 1, 2023

Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (B) Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed. This requirement was not met as evidenced by: Licensee did not ensure that R2 did not have unsecured medication in R2’s living unit, which poses an immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Licensee shall submit a Plan of Correction by POC date to ensure that staff receive in-service training on securing medications and not leaving medications unsecured in resident living units. Once training is completed, the Licensee agrees to submit training logs to CCL.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87633(d) · Plan of correction due date: Nov 1, 2023

87633(d) Hospice Care of Terminally Ill Residents (d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client’s care needs are being met at all times. This requirement was not met as evidenced by: Licensee did not ensure that staff followed R3’s hospice care plan by contacting R3’s hospice agency before administering comfort paks to R3.the state’s words, verbatim · CDSS document, Oct 31, 2023

Plan of correction: Licensee shall submit a Plan of Correction by POC date to ensure that facility staff will receive in-service training on contacting the hospice agency prior to administering comfort paks to residents as directed in the resident’s hospice care team plan. Once training is completed, the Licensee agrees to submit training logs to CCL.

Allegation investigated: Staff are not sufficient in numbers or competency to meet resident's needs.

Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Steven Silacci. The Department received a complaint with the above allegation on 09/30/2020 and conducted an initial complaint visit on 10/12/2020. The Department conducted an additional complaint investigation visit on 08/23/2023. During visit on 08/23/2023, LPA Marrufo conducted interviews with Administrator Steven Silacci and requested to interview staff who were employed when the complaint allegation was reported, which was 09/2020. Administrator Silacci brought 7 staff, staff S1-S7, for LPA Marrufo to interview. Administrator Silacci and staff S1-S5 reported working with resident R1. However, staff S4 provided care to R1 but did not provide medications and S5 did not provide care to R1. See LIC9099-C for more information. Page 1 of 2. Unfounded During interview on 08/23/2023, facility staff S1 stated that resident R1 had a behavior of running throughout the facility. S1 stated the facility policy regarding use of anti-anxiety PRN medications is for staff to attempt a redirection first before administering any anti-anxiety PRN medications. S1 stated that this policy was followed with R1 when R1 would run throughout the building. S1-S4 stated staff would attempt to redirect R1 before administering anti-anxiety PRN medications. S1 also stated during that time, there were always sufficient staff at the facility. Staff S5 stated to have provided redirections to R1 but did not have knowledge as to whether or not R1 was given anti-anxiety PRN medications. Staff S6-S7 stated to have not worked with R1. Staff S1, S2, S3, S6, S7 stated that there were enough staff at the facility to meet the residents’ needs in the year 2020. Staff S4 and S5 stated that there were many staff shortages due to the COVID pandemic at that time. Facility Staff Schedules from July and August 2020 show a full schedule of staff. R1’s Physician’s Orders from 12/08/2020 state Lorazepam is a PRN medication for R1 to be used as needed for anxiety. R1’s PRN Medication Log from 12/2020 records the interventions given prior to administering Lorazepam medication for anxiety. The interventions include “One on one,” “Music,” “Visited with Resident,” and “Photo Albums.” This agency has investigated the complaint allegations listed. Based on interviews and review of records, the CCLD has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report was reviewed with Steven Silacci and a copy of the report was provided. Page 2 of 2. END REPORT.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 26-AS-20200930112546