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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 12/28/2021
Date Signed: 12/28/2021 11:27:34 AM


Document Has Been Signed on 12/28/2021 11:27 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



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: 50DATE:
12/28/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:RACHEL DAVIDTIME COMPLETED:
11:00 AM
NARRATIVE
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Donna Gurriere, Licensing Program Analyst was in contact and met with Rachel David, Administrator.

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.

During a review of the facility’s Stipulation and Waiver Order, it was determined that the facility has not been following item “T” in which it states “Respondents shall within 60 days of execution of this agreement, obtain a consultant to come to the facility on a quarterly basis for a period of three years to evaluate the facility’s compliance with the Regulations and assessing systems to include, but not be limited to: care and supervision, dementia care, medication management, documentation, reporting requirements, hospice care and care plans. Facility must submit consultant’s evaluation to its Licensing Program Analyst on a quarterly basis. The consultant needs to be reviewed and approved by the Regional Manager of the Adult and Senior Care Program Office.”

The administrator reported that the Allen Flores Consulting Group did not come into the facility most of 2020 and 2021 to provide consulting, due to the Covid pandemic. A letter was received on 12/10/21 from the consulting group confirming the information. The facility did not reach out to the licensing agency to ask if this part of their Stipulation and Waiver Order could be negotiated or waived during the time of the pandemic for the years of 2020 and 2021.

The facility has violated their Stipulation and Waiver Order and shall therefore be cited under Health and Safety Code (H&S) 1569.50(3) Conduct Inimical. The H&S Code is being cited on the attached LIC 9099D. Appeal rights were provided, and the exit interview conducted.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (530) 895-5033
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021
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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Document Has Been Signed on 12/28/2021 11:27 AM - It Cannot Be Edited

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 COHASSET RD., STE. 170
CHICO, CA 95926


FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
12/29/2021
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: 12/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2021
LIC809 (FAS) - (06/04)
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