045001959-7-28-2021-25-AS-MSEY-C5ESH3-20210730135252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 07/28/2021
Date Signed: 07/28/2021 10:59:51 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
04/02/2021 and conducted by Evaluator Pheej Cheng

COMPLAINT CONTROL NUMBER: 25-AS-20210402092118

FACILITY NAME:	WINDCHIME OF CHICO		FACILITY NUMBER:	045001959
ADMINISTRATOR:	DAVID, RACHEL		FACILITY TYPE:	740
ADDRESS:	855 BRUCE RD		TELEPHONE:	(530) 566-1800
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	120	CENSUS: 57	DATE:	07/28/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rachel David; Administrator		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Facility failed to provide documents.

INVESTIGATION FINDINGS:

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On 7/28/21 at 9:30 AM, Licensing Program Analyst (LPA) Cheng conducted an unannounced complaint invesetigations visit regarding the allegation above. LPA Cheng met with Administrator Rachel David and explained reason for visit. Prior to initiating the 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 facility's front desk personnel and their automated system.

Continuation on LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20210402092118

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: 07/28/2021

NARRATIVE

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Based on interview statements and documents obtained on 7/1/2021, LPA determined that the above allegation did occur. Facility received RP's document request via fax on 3/30/2021 and then RP's document request via mail on 4/5/2021. RP's request indicate that RP was legally representing R1 on R1's behalf. Facility made several attempts to reach RP via phone from 4/5/21 to 4/16/21 and was unsuccessful. According to S1's knowledge, facility's legal unit is handling the submission of R1's documents to RP and S1 is unsure if the documents have been submitted.

Based on LPA information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted and a copy of the report along with appeal rights were given.

SUPERVISOR'S NAME: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20210402092118

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/09/2021 Section Cited HSC 1569.269(21)	1 2 3 4 5 6 7	1569.269 Enumerated Rights; severability (21) To have prompt access to review all of their records and to purchase photocopies. Photocopied records shall be promptly provided, not to exceed two business days, at a cost not to exceed the community standard for photocopies. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed to conducted an in-service training regarding HSC 1569.269 and submit training materials along with signatures of participants to LPA by POC date.
	8 9 10 11 12 13 14	Based on staff statement and documents obtained, Licensee did not provide 1 of 1 resident's requested document to RP which poses a potential health and safety risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Maribeth Senty	TELEPHONE: (915) 263-4813
LICENSING EVALUATOR NAME: Pheej Cheng	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC9099 (FAS) - (06/04)

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