045001959-9-21-2022-25-AS-APEZ-CKDT8P-20221020143041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 09/21/2022
Date Signed: 09/21/2022 03:44:24 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
08/26/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220826143128

FACILITY NAME:	WINDCHIME OF CHICO		FACILITY NUMBER:	045001959
ADMINISTRATOR:	VONWAL, JEFFREY		FACILITY TYPE:	740
ADDRESS:	855 BRUCE RD		TELEPHONE:	(530) 566-1800
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	120	CENSUS: 52	DATE:	09/21/2022
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator- Jacob Primeau		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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- Staff engaged in inappropriate behaviors in the presence of residents.
- Staff are not wearing masks.

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. 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 reviewed documents, conducted interviews and gathered statements from facility staff.

The Department has completed the investigation and the following are the finding:
On Sunday 8/21/2022, Administrator and Executive Director Jeff Vonwal (ED), while residing in the facility set
off the fire alarm from “steam from the shower.” Community Care Licensing Division Complaint Hotline (CCIB) received a complaint on 8/26/2022 regarding the incident.

Continue on page LIC 9099-C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (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)

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Control Number 25-AS-20220826143128

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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During the incident, ED ran from his bedroom to the front desk in the lobby with only shorts on. ED was seen without a shirt, shoes or mask on in multiple common areas of the facility to include the front desk, lobby, dinning room, kitchen and medication room. During this time period ED locked himself out of his bedroom and did not know how to regain access. All staff interviewed stated they saw the ED during this time without a mask on. ED told CCLD he put one on just outside of his room that he pulled from a PPE Cart. No one could corroborate the Eds account of what occurred. The Department requested ED complete a declaration and was provided an LIC 855 (Declaration form) on 8/31/2022. ED agreed to submit the declaration no later than 9/2/2022. Due to the Department not receiving the LIC 855 from the ED, on 9/14/2022 the Department notified Milestone Retirement (Licensee) via e-mail that this document was not received. To date, 9/21/2022, the Department has not received requested document. On 8/3/2022, the facility was cited due to the ED not wearing a mask while in the common area of the facility. Multiple witness completed the Declaration and attested to seeing the ED either without a mask on while in the common areas of the facility or pulling the mask away from his face while speaking with residents in the facility.

On April 20, 2022 California Department of Public Health TOMÁS J. ARAGÓN, M.D., Dr.P.H.
State Public Health Officer & Director released guidance for use of face masks. This guidance states long term care settings and adult and senior Care facilities, masks are required for all individuals in the following indoor settings, regardless of vaccination status.

During the visit on 8/31/2022, The Department observed the ED in a surgical mask however all other staff were in a N95 respirator. The Department requested to see the staff schedule for the day. The Department was only able to verify that one direct care staff was on duty on the assisted living side of the facility. Cathy Helton Regional Director of Operations stated that the other direct care staff had tested positive that morning for COVID 19. To date the Department has not received an incident report or template regarding the positive as required by regulation. The facility was previously cited for failure to report a COVID 19 outbreak on 8/3/2022.

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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (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)

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Control Number 25-AS-20220826143128

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 09/22/2022 Section Cited CCR 87405(d)(2)	1 2 3 4 5 6 7	87405 Administrator - Qualifications and Duties 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. This requirement is not me as	1 2 3 4 5 6 7	Administrator agrees to read and review PIN 20-22-ASC issued on 2/7/2022 and submit a letter of understanding to CCL by POC due date, 09/22/2022.
	8 9 10 11 12 13 14	evidenced by: Based on interviews Administrator was seen not wearing a mask per California Department of Public Health released guidance for use of face masks. This guidance term care settings and adult and senior care faciltiies, masks are required for all individuals in the following indoor settings, regardless vaccination status. Which poses an immediate health, sasfety, and personal rights violation to residents in care.	8 9 10 11 12 13 14
Type B 11/03/2022 Section Cited CCR 87468.1(a)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations. This requirement is not met as evidenced by: Based on inteviews Administrator engaged in inappropriate	1 2 3 4 5 6 7	Admininstrator agrees to read regulation 87468.1 and submit a letter of understanding to CCL by POC due date, 11/03/2022.
	8 9 10 11 12 13 14	in the presence of residents. Which poses a potential health, sasfety, and personal rights violation to residents in care.	8 9 10 11 12 13 14

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 Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (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)

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