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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 05/06/2022
Date Signed: 05/06/2022 06:48:14 PM


Document Has Been Signed on 05/06/2022 06:48 PM - 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: 58DATE:
05/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
06:21 PM
MET WITH:Rachel David, AdministratorTIME COMPLETED:
07:45 PM
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On 05/06/2022 at 6:00pm, Licensing Program Analyst (LPA) Misty Valencia conducted an unannounced Case Management visit and met with Administrator Rachel David. 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 Masks, additionally, LPA was screened by front desk personnel.

The purpose of LPA's visit was to delivering an Order for a Staff regarding an Individual of Immediate Exclusion from all facilities and the Order to Licensee/Facility of Immediate Exclusion From the facility. LPA informed Administrator the purpose of today's visit . LPA delivered notice of "Immediate Exclusion" to Administrator and explained the "Immediate Exclusion" notice indicating that an employee, cannot be allowed to work, be present and/or live in a CCL licensed facility or have contact with clients in any residential facility or child day care licensed by the California Department of Social Services.

Admin reported that she understood. A copy of this report was provided to Administrator.
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Misty ValenciaTELEPHONE: (530) 895-5820
LICENSING EVALUATOR SIGNATURE:
DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/06/2022
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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