045001959-12-28-2021-25-AS-RLBN-CA8VN9-20211231153444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 10/19/2021
Date Signed: 12/28/2021 11:17:12 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
06/10/2021 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20210610131136

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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Resident was not accorded dignity in relationships with staff.

Amended Report

INVESTIGATION FINDINGS:

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Donna Gurriere, Licensing Program Analyst was in contact with Rachel David, Administrator. It was alleged that Resident was not accorded dignity in relationships with staff.

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

Unsubstantiated

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)

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Control Number 25-AS-20210610131136

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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Amended

Resident was not accorded dignity in the resident’s relationships with staff.
During the interview process, the administrator and nine staff persons were interviewed. Also interviewed was the resident. Documents collected for review were the resident’s Physician Report, Service Agreement, Medication Log and Call Light Times. Most care providers stated that the allegation did not happen, or that they were unaware of the allegation, the nurse involved was not available for comment and the resident stated he is unaware of not being treated with dignity in the resident’s relationships with staff.

Overall, it could not be proven that the resident was not accorded dignity in the resident’s relationships with staff. Although the allegation may have happened, or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated. No deficiencies cited.

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)

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