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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 08/31/2020
Date Signed: 09/01/2020 06:56:20 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME:WINDCHIME OF CHICOFACILITY NUMBER:
045001959
ADMINISTRATOR:DAVID JR, RICKYFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 71DATE:
08/31/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:RACHEL DAVIDTIME COMPLETED:
03:30 PM
NARRATIVE
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On 8/31/20 Donna Gurriere, Licensing Program Analyst and Rayna Bryson, Licensing Program Manager conducted an unannounced case management visit and met with Rachel David. The purpose of this visit is to provide Windchime of Chico with findings as follows.

California Department of Social Services Community Care Licensing received information that on 8/1/20, a caregiver (S1), worked a shift while symptomatic. S1 did so after contacting a medication technician who relayed the message to the Director of Health and Wellness. S1 continued to work symptomatic from 8/1/2020 - 8/4/2020. At no point during this period did management follow up with S1 regarding his symptoms or the potential hazard these symptoms posed to residents in care. The facility or its management did not assess if the symptoms were a significant threat to the well-being of residents or determine if S1 should have been sent home as a result of their symptoms.

Deficiencies are cited per California Code of Regulations, Title 22, and listed on LIC 809D. Failure to submit Proof of Corrections (POC's) by Plan of Correction date may result in civil penalties.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2020
Section Cited

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Personnel Requirements - Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
Type A
09/01/2020
Section Cited

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Conduct Inimical - Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2020
LIC809 (FAS) - (06/04)
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