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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:35:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Sarena Keosavang
COMPLAINT CONTROL NUMBER: 25-AS-20220823083904
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: 52DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator- Jacob Primeau TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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- Facility air conditioning unit in disrepair.
- Staff not keeping the facility free of hazards.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Sarena Keosavang and Jacob Williams arrived at the facility unannounced on 09/21/2022 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 08/23/2022. LPA met with Administrator,Jacob , and explained the purpose of the visit. LPAs wore N-95 masks and were screened by facility upon entry.

Throughout the course of the complaint investigation the Department conducted interviews and gather statement from facility staff.

Allegation- Facility air conditioning unit in disrepair. – Substantiated.
On 08/31/2022, LPA Keosavang toured the interior and exterior of the facility. LPA observed air conditioner in disrepair in the Memory Care unit. Interview statement gathered from staff (S1) indicated that three (3) air conditioning unit has been broken for two and a half months in the Memory Care Unit. This poses an immediate health and safety risks to residents in care.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 25-AS-20220823083904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/21/2022
NARRATIVE
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Allegation- Staff not keeping the facility free of hazards. – Substantiated.

Interview statement gathered from S1 indicated due to air conditioning unit in disrepair, condensation build up is causing water leakage from ceiling in the Memory Care Unit. On 08/31/2022, LPA toured the Memory Care Unit and observed two medium size trash can in the hallways filled with water. Towels were on the floor next to the trash can to avoid water leakage. Trash cans is a tripping hazard and can cause residents to trip and fall. This is an immediate health and safety risks to residents in care.

Due to this information CCL finds the allegation to be SUBSTANTIATED. – A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited on the attached LIC 9099-D.

Appeal rights were provided.

An exit interview was conducted, and a copy of the report left at the facility.

SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 25-AS-20220823083904
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors This requirement is not met as evidenced by:
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Administrator agrees to repair AC unit by POC due date, 10/06/2022. Administrator agrees to submit invoice to Licensing.
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Based upon observation and interviews, Licensee failed to keep facility in good repair at all times. LPA observed air conditioning unit in disrepair. Water leakage in front of resident's bedrooms. This poses an immediate Health, Safety and/or Personal Rights risk to clients in care.
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Type A
09/22/2022
Section Cited
CCR
87307(a)(6)
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87307 Personal Accommodations Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply: All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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Licensee agree to remove trash bins to ensure hallways are free from obstruction to prevent tripping hazards after AC leakage has been repaired.
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This requirement is not met as evidenced by: Based upon observation and interview with S1, facility failed to keep the memory care unit free of obstruction. LPA observed trash cans in the hallway filled with water which can cause residents to trip and fall. 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: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASSET RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/23/2022 and conducted by Evaluator Sarena Keosavang
COMPLAINT CONTROL NUMBER: 25-AS-20220823083904

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: 52DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator- Jacob Primeau TIME COMPLETED:
04:30 PM
ALLEGATION(S):
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2
3
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5
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9
Facility staff allow resident to sleep in common area.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Sarena Keosavang and Jacob Williams arrived at the facility unannounced on 09/21/2022 to deliver complaint findings for a complaint Community Care Licensing (CCL) received on 08/23/2022. LPA met with Administrator, Jacob Primeau, and explained the purpose of the visit. LPAs wore N-95 masks and were screened by facility upon entry.

Throughout the course of the complaint investigation the Department conducted interviews and gather statements from facility staff. Interview statement received from S1 and S3 denied staff allowing residents to sleep in common areas due to AC Unit not working.

Due to the information above, LPA finds the allegations to be UNSUBSTANTIATED meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted. Copies of report porivded.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4