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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 07/08/2021
Date Signed: 07/08/2021 11:59:34 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/06/2021 and conducted by Evaluator Misty Valencia
COMPLAINT CONTROL NUMBER: 25-AS-20210706114930
FACILITY NAME:WINDCHIME OF CHICOFACILITY NUMBER:
045001959
ADMINISTRATOR:DAVID, RACHELFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 55DATE:
07/08/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Rachel David EDTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Resident's medication orders are incomplete.
INVESTIGATION FINDINGS:
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On 07/08/2021, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced complaint investigation visit to open up a complaint regarding the above allegation and met with Executive Director Rachel David. Prior to initiating the complaint visit, LPA completed required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID-19 infection to affirm no COVID-19 related symptoms; contacted Administrator and completed a facility risk assessment. LPA ensured they applied hand sanitizer before entering the facility and the following Personal Protective Equipment (PPE) was worn: Surgical Mask. Additionally, LPA was screened by Administrator Rachel David.

Continued on 9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 25-AS-20210706114930
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
VISIT DATE: 07/08/2021
NARRATIVE
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Allegation:Residents medication orders are incomplete.

During the interview with ED, Staff 1(S1) and records reviewed it was determined that there was not any issues with residents medications order incomplete. LPA received Resident 1 (R1)'s physicians report 602, medications list and administrations record. R1 did not enter the facility until 6/30/2021, and the facility already had signed doctors medications list on 06/11/2021. The preponderance of evidence standard has not been met. The allegation is unfounded.


"This agency has investigated the complaint alleging that Residents medication orders are incomplete. We have found that the complaint of Residents medication orders are incomplete was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint."


There were no citations issued during today's visit, copy of report was given.

An exit interview was conducted
SUPERVISOR'S NAME: Kevin MknellyTELEPHONE: (209) -81-1925
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2