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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 08/03/2022
Date Signed: 08/03/2022 04:52:34 PM


Document Has Been Signed on 08/03/2022 04:52 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: 53DATE:
08/03/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Milestone Cathy Helton
Windchime Jeff Vonwal		TIME COMPLETED:
04:30 PM
NARRATIVE
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An office meeting was held on 08/03/2022, via Microsoft Teams to discuss topics listed in this report.
The following Licensing staff were present:
Licensing Program Manager (LPM) Laura Munoz, Troy Ordonez and Licensing Program Analyst (LPA) Jaclyn Avila, Butte County Public Health Miranda and Linda Lewis infection control specialist
The following representatives present:
Ginger Tarabochia – Director of compliance and regulatory affairs, Cathy Helton RVP, Melissa Nurse Consultant, Natalie Ross, Jeff Vonwal new Administrator
The following topics were covered during today's meeting:
COVID 19 in the building
Facility's failure to report to CCLD
Executive Director/Administrator Did not test when experiencing symptoms
Executive Director/Administrator lack of knowledge regarding reporting requirements
Executive Director/Administrator walked through facility with no mask on
Executive Director/Administrator told LPA he was not feeling well
Executive Director/Administrator text LPA he tested positive for COVID 19
Executive Director/Administrator stated he was going to stay in the building to show his staff that he is working due to being the new administrator effective 7/25/2022
CCLD is requesting the following which are due by COB on 8/4/2022
Line list of all response testing
Report to CCL-LIC 624 and demographic templates
Report to LTCO
Report to Public Health
Training for staff of infectious control plan/call out procedures
CCL will refer the facility to local public heath and request an HAI (Healthcare - Associated Infections ) visit.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 08/03/2022 04:52 PM - 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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2022
Section Cited

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87470(b)(2) Infection Control Requirements
In addition to subsection (a), when one or more residents in the facility are diagnosed with a communicable disease, the following shall apply: All staff ...providing direct care to a resident who has a communicable disease shall wear appropriate Personal Protective Equipment (PPE) to prevent
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exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection.
This requirement is not met as evidenced by: Based upon observation the Licensee
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failed to ensure Administrator was wearing a mask during a COVID 19 outbreak in the facility and while experiencing symptoms.

This poses an immediate Health, Safety and/or Personal Rights risk to residents in care

Type A
08/04/2022
Section Cited

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87211(a)(2) Reporting Requirements- Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:Occurrences, such as epidemic outbreaks, ... which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported
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within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to report an outbreak to CCLD
This poses an immediate Health, Safety and/or Personal Rights risk to residents in care
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 08/03/2022 04:52 PM - 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: 08/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)

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Type A
08/04/2022
Section Cited

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87405 (d)(2) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.(2) Knowledge of and ability to conform to the applicable laws, rules and regulations
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This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to follow applicable laws, rules and regulations related to COVID 19.

This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care
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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: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 08/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: 08/03/2022
NARRATIVE
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During the meeting Milestone identified Cathy Helton as the point of contact while the administrator is out. Report will be e-mailed to Cathy. Cathy has agreed to sign and return report via e-mail.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 809D). Appeal Rights were explained and provided to the facility representative listed above and an Exit Interview was conducted. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 08/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4