045001959-6-21-2022-25-AS-JAVA-CFLPXL-20220621114231

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 06/16/2022
Date Signed: 06/21/2022 11:44:26 AM

Document Has Been Signed on 06/21/2022 11:44 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 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: 56	DATE:	06/16/2022
TYPE OF VISIT:	Office	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Rachel David, Administrator		TIME COMPLETED:	03:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	An office meeting was held on 06/16/2022 at 1:30 PM on a Microsoft Teams Meeting video conferencing system to review the stipulation adopted on 6/07/2022 and the next steps. This Stipulation shall be posted in a conspicuous place at the facility for the duration of the probationary period. The following were in attendance: Regional Manager (RM) Alycia Berryman, Licensing Program Manager Troy Ordonez, Licensing Program Analyst Jaclyn Avila, WINDCHIME ASSISTED LVG, ASSOCIATES; MILESTONE RET and Allen Flores Group. (RM) Alycia Berryman discussed the purpose and elements of this type of meeting. The Stipulation was reviewed with Representatives, Administrators, and Licensees who expressed their understanding. Items discussed at the meeting included, but not limited to: Stipulation contents · Findings · Revocation of License - Stayed with Probation · Limitations and conditions · Monitoring Penalty - Rescinded · Future Application for License, Registration, Certification or Approval · Licensure, Certification or Approval; Application Denial, Tolling of Probationary Period Cont'd on 809-C

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

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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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
	VISIT DATE: 06/16/2022

NARRATIVE

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· Completion of Probation
· Violation of Stipulation Term
· Monitoring Fee
· Department's Authority
· Waiver of Hearing Rights; Waiver of Appeal/Modification Rights/Waiver of Claims
· Severable terms
· Public Records
· Signatures
· Counterparts
· Effective Date: (6/7/2022 – 12/07/2023)
· No Oral Modification
· Representations RE. Corporate Licensee

The Licensees/Respondents/Representatives stated they would abide by the following:
· Abide by the contents/terms of the Stipulation (submit all documents timely)
· Operate the facility in strict compliance with the regulations and statues governing the operation of a residential care facility for the elderly.

CCLD will do the following:
· Increase monitoring

Per the California Code of Regulations, Title 22, Division 6, Chapter 8, no violations cited during this visit. An exit interview was conducted, and a copy of this report was provided via email and an electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Laura Munoz	TELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn Avila	TELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2022

LIC809 (FAS) - (06/04)

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