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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 06/10/2022
Date Signed: 06/10/2022 10:22:48 AM


Document Has Been Signed on 06/10/2022 10:22 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: 60DATE:
06/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Rachel DavidTIME COMPLETED:
10:35 AM
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On 6/10/2022, Licensing Program Analyst (LPA) Jaclyn Avila conducted an unannounced complaint visit. During the visit LPA learned of an incident that occurred the day before.

Administrator Rachel David reported that Resident (R1) attempted suicide then requested assistance from staff. Staff immediately tended to R1 while summoning assistance from 911. When paramedics and police arrived R1 disclosed his intention. Police searched for object used and found a "small pocket knife" on R1's person.

This Department reviewed R1's LIC 602 (physicians report) and Care Plan. R1 is independent. R1 stays in R1's room and when R1 leaves R1's room the door is locked preventing other residents from entering. R1 did not indicate to staff what R1 was going to do.

Prior to the incident, Staff would enter and check on R1 hourly. At the time of the incident, Staff transferred R1 to the toilet at approximately 5:45AM. Due to R1 not needing assistance to use the toilet, staff left and waited for the call light to return to transfer R1 to R1's chair. R1 pulled the call light at 6am and staff responded at 6:10 AM. R1 is currently at the hospital.

The Department determined the facility responded appropriately and within regulation.

No citations were issued during today's visit.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2022
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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