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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 08/17/2022
Date Signed: 08/17/2022 08:44:24 PM


Document Has Been Signed on 08/17/2022 08:44 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:VONWAL, JEFFREYFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 53DATE:
08/17/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Jeff Vonwal, AdminstratorTIME COMPLETED:
09:00 PM
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On 8/17/2022 at 4:00 PM, Licensing Program Analyst (LPA) Jaclyn Avila met with Administrator Jeff Vonwall and Director of Health and Wellness (DHW) JaLuisa Tippens to conduct a case management visit. The purpose of today's visit was to ensure compliance with the terms and conditions set forth in the Stipulation and Waiver; and Order effective June 7th, 2022.

LPA asked where the Stipulation and Waiver was posted as per stipulation C. Administrator said he did not know and later stated he has a stipulation book. DHW and Resident Care Director (RCD) Jessie Hinajosa both stated the stipulations were not posted but there is a sign stating stipulation available upon request.

LPA requested the written summary of its hiring and training practices, including job descriptions for each position at the facility as per Stipulation AA. Administrator provided the training plan for Windchime and stated it was previously sent per Milestone however CCLD has not received it. Administrator said he would look into where remainder of the documents were and provide them to CCLD.

LPA asked Administrator if the med techs were being counted as direct care staff. Administrator said he did not know but knew the ratios of 1:6 in memory care and 1:10 in assisted living. Staff interviews revealed med techs were being included in the ratio. Per the stipulation med tech shall not be included in the ratio. LPA obtained copies of the June 2022- present staff schedules and observed that the facility is not staffing the facility with the minimum requirements to meet the needs of the residents in care.

LPA requested rosters as per Stipulation H. Staff rosters must be completed weekly and available upon request. LPA was not provided with this and administrator said he would read through the stipulation and start. The facility has not been preparing weekly or monthly rosters as required.
SUPERVISOR'S NAME: Laura MunozTELEPHONE: (916) 263-4743
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
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: 08/17/2022
NARRATIVE
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The facility has informed current and prospective residents that the facility is currently operating under a probationary license.

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: 08/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/17/2022 08:44 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: 08/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2022
Section Cited

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1659.50(3)-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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This requirement is not met as evidenced by: Based upon observation, interview and record review. The Licensee failed to abide by the Stipulation Waiver and Order.

This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
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Type B
08/18/2022
Section Cited

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1569.38-Posting of licensing reports; disclosure to new residents-(e) the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, ... where the facility license is posted, or any other easily accessible location in the facility.
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This requirement is not met as evidenced by: Based upon interview and observation, the Licensee failed to post the Stipulation Waiver and Order
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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: 08/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2022
LIC809 (FAS) - (06/04)
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