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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 08:24:01 PM


Document Has Been Signed on 08/17/2022 08:24 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 - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator Jeff VonwalTIME COMPLETED:
08:30 PM
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On 8/17/2022 at approximately 8:15 AM, Licensing Program Analyst (LPA) Jaclyn Avila conducted a tour of the memory care unit with Administrator Jeff Vonwal related to a complaint investigation. The following deficiencies were observed during the tour.

LPA toured the kitchenette in memory care. LPA opened the cabinet under the sink and observed multiple cleaning solutions. Solutions were labeled Multi-purpose and glass cleaner. Administrator said he would follow up with staff regarding locking items.

LPA observed room 119 door was propped open. LPA toured the room with administrator. Under the sink in the bedroom portion of the suite, LPA observed a broken ceramic bowl that had sharp edges, in the bathroom LPA observed an electric razor. LPA observed that the oak cabinet door behind the bedroom door was unlocked. LPA opened the door and observed multiple personal hygiene items to include: deodorant, shampoo, shaving cream and a razor. The door to this bedroom was propped open using a clothing hanger. LPA later reviewed the LIC 602 (Physicians Report) report which notated that Resident is at risk if allowed direct access to personal grooming and hygiene items.

LPA explained to administrator that given the unit is a memory care unit there may be residents who wonder and who are also at risk if they are allowed access to personal hygiene items.

At 1:15 PM, LPA observed Clorox wipes on the table in the administrator office on a table. The door to this office was left open. There were not staff in or around the office leaving the disinfectant accessible to residents. LPA located Director of Health and Wellness and requested she secure the disinfectant.

Cont'd on LIC 809 C
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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During the visit LPA asked Administrator for the plan of correction that was due on 8/4/2022 for their previous citation that was issued on 8/3/2022 for 87309(a) Storage Space- Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. Administrator left and returned with a double sided printed report and told LPA that was all that was given to him. LPA informed Administrator, LPA's printer does not print double sided.

Administrator then accused LPA of not providing him with the report. Present during the accusation was the facility's DHW. LPA showed the administrator the report with his signature on it dated 8/3/2022. LPA told administrator it was read and reviewed with him and he signed it. LPA then printed the report and personally handed it to him at the conclusion of the visit on 8/3/2022. The administrator left the office and returned with the report. Administrator began to ask staff if it was their hand writing on the report which they denied. One staff was on leave of absence during the site visit.

Administrator then stated he handed the report containing the POC to staff to be faxed which wasn't done. Administrator said he could conduct the POC by tomorrow 8/18/2022.

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 08:24 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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87705 (g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. (1) Evidence means documentation from the resident’s physician that the
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resident is at risk if allowed direct access to personal grooming and hygiene items.
This requirement is not met as evidenced by: Based upon observation and record review the Licensee failed to store personal hygiene items in a way that prevented direct access. This poses an immediate Health, Safety and/or Personal Rights risk to clients in care
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Type A
08/18/2022
Section Cited

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87309(a) Storage Space-Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Based upon observation Licensee failed to store cleaning solutions inaccessible to clients in care.

This poses an immediate Health, Safety and/or Personal Rights risk to clients 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: 08/17/2022
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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