045001959-10-19-2021-25-AS-RLBN-C86TLE-20211026144923

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 10/19/2021
Date Signed: 10/19/2021 11:26:55 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
06/04/2021 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20210604154518

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: 50	DATE:	10/19/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	RACHEL DAVID		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility is retaining a resident with Clostridium Difficile "C Diff" a prohibited health condition.
Facility is violating their Stipulation with caregiver to resident ratios.

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact with Rachel David, Administrator. It was alleged that the Facility is retaining a resident with Clostridium Difficile "C Diff" a prohibited health condition and the
Facility is violating their stipulation with caregiver to resident ratios.

LPA Gurriere completed the required COVID-19 testing protocols, and a daily self-screening questionnaire for symptoms of COVID 19 infection to affirm no COVID-19 related symptoms. The administrator/staff person was contacted to complete a facility risk assessment. LPA Gurriere ensured that hand sanitizer was applied before entering the facility and the following Personal Protective Equipment (PPE) was worn: N-95 mask. Additionally, LPA Gurriere was screened by a staff person upon entering the facility.

continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

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 4

Control Number 25-AS-20210604154518

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: 10/19/2021

NARRATIVE

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continued

Facility is retaining a resident with Clostridium Difficile “C Diff” a prohibited health condition.

During the interview process, the administrator and ten staff persons were interviewed. In addition, documents pertaining to the resident were obtained to include the physician’s report, assisted living service agreement and the resident’s discharge documents from the post-acute facility. All staff persons that provided care, confirmed that the resident did have C Diff, a highly contagious infection that causes severe diarrhea and colitis. Staff persons reported that they were required to use Personal Protective Equipment (PPE) to include gowns, gloves, face masks, booties and hair nets during the care of Resident 1. C Diff is considered a Prohibited Health Condition which is listed as a serious infection and the facility is required to obtain an exception from licensing. The facility did not obtain an exception, as required.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be Substantiated. California Code of Regulations, (Title 22) is being cited on the attached LIC 9099D. Appeal rights were provided, and the exit interview conducted.

continued

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 25-AS-20210604154518

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: 10/19/2021

NARRATIVE

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Facility is violating their Stipulation with caregiver to resident ratios.

During the investigation, the administrator and ten staff persons were interviewed. In addition, documents were obtained to include work schedules with staffing names, hours and shift times. The administrator reported that during the past month, she has been “passing medications” to assist with the staffing ratios. Staff persons were interviewed, and most staff persons felt that they were “short staffed”; however, they did not know what the Stipulation and Waiver Order Agreement was regarding the caregiver to resident ratios.

As mentioned, the administrator advised that she has assisted with passing medications, which also has included that she has provided some caregiving to the residents. The administrator reported that the facility has had some staffing concerns due to the pandemic of Covid 19. The administrator stated that last week six new caregivers were hired.

The Stipulation and Waiver Order states in part “Staffing levels referenced shall be independent of each other and shall only include caretaking staff, excluding directors, receptionists, food handlers, aids, drivers, housekeepers and any person whose job description does not primarily involve direct client care.”

In reviewing the work schedules, it appears that the facility has the appropriate coverage. However, the Stipulation and Waiver Order does not allow for the administrator (director) to participate or be included in the ratios by providing care to the residents; therefore, the allegation is Substantiated.

Based on the evidence obtained, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be Substantiated. California Code of Regulations, (Title 22) is being cited on the attached LIC 9099D. Appeal rights were provided, and the exit interview conducted.

SUPERVISOR'S NAME: Rayna L Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 25-AS-20210604154518

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: 10/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/26/2021 Section Cited CCR 87615(a)	1 2 3 4 5 6 7	Prohibited Health Conditions - Persons who require health services for or have a health condition including but not limited to those specified below shall not be admitted or retained in a residential care facility for the elderly: Staphylococcus aureus (staph) infection or other serious infection.	1 2 3 4 5 6 7	The administrator agrees to submit to the licensing agency a policy that outlines the Prohibited Health Condition requirements. Administrator shall submit within one week.
	8 9 10 11 12 13 14	Based on interviews and records reviewed, the licensee did not obtain an exception prior to taking in a resident with C Diff. This poses an immediate health and safety risk to a resident in care.	8 9 10 11 12 13 14
Type A 10/26/2021 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities - Residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:	1 2 3 4 5 6 7	The administrator agrees to ensure that the facility is following the Stipulation and Waiver Order as stated. The administrator will submit to the licensing agency how this will be accomplished in the future.
	8 9 10 11 12 13 14	To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. Based on interviews and records reviewed, the licensee did not follow the Stipulation and Waiver Order of caregiver to resident ratios.	8 9 10 11 12 13 14

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 Bryson	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021

LIC9099 (FAS) - (06/04)

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