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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 03:53:59 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
08/29/2022 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20220829083205
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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- Resident eloped.
- Failure to report.
- Retaliation for participated in the filing of a complaint.
- Administrator yelled at staff in front of residents.
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 regarding the allegations listed above.

The Department has completed the investigation and the following are the finding:
Allegations: Resident eloped; facility failed to report
Record review revealed Resident (R1) had a history of eloping. R1’s Physician’s Report (LIC 602) dated 4/19/2022 states R1 has a primary diagnosis of dementia and is not able to leave the facility unassisted.

Continue on page LIC 9099-C.
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 5
Control Number 25-AS-20220829083205
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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Per the progress notes for R1 dated 4/21/2022, former ED documented wanderguard placed on resident for safety, staff should redirect if R1 is confused. Progress notes dated 6/18/2022 notates R1 pulled the fire alarm, went outside and was able to get out of the back gate due to having pulled the fire alarm. R1 was located outside of the facility in front of the building. Progress notes dated 8/24/2022 documents resident pulled fire alarm at the north gate exit and was able to exit. R1 was located outside of the facility near the lake at the “smoker’s bench.” Facility staff identified increased supervision was needed and notified family however increased supervision is not notated to have taken place. Progress notes dated 8/26/2022, notates R1 cut off wanderguard and eloped out of the memory care fire exit door.

This Department conducted a site inspection on 8/31/2022. R1’s room was located on the second floor of the facility near the fire escape stairwell. R1 went down the 2nd floor south stairwell which leads to an “emergency fire exit only” door. R1 was able to exit this door to the exterior of the southwest end of the facility which leads to Bruce Road. In addition to this exit leading to a major artery, there is a steep decline just outside of this door leading to the road.

R1 was located on the west exterior of the building. R1 was located due to staff noticing through a window during a meeting with the Executive Director (ED) Jeff Vonwal that R1 was outside the facility unassisted.

At no time did the facility notify licensing or submit an incident report related to the elopement as required. During the site visit on 8/31/2022, this Department explained the incident was an elopement and requested a written report which to date has still not been submitted. This Department requested a Declaration (LIC 855) regarding the incident from the ED due on agreed upon date of 9/2/2022. The Declaration has not been received to date (9/21/2022). 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.

Allegation: retaliation for participated in the filing of a complaint.

All staff interviewed and declarations provided to the Department provide that on August 25th, 2022 at 2PM, Executive Director (ED) Jeff Vonwal held an all staff meeting outside in the Courtyard of Windchime of Chico. During this meeting ED told staff that by calling licensing and speaking with the LPA (Licensing Program Analyst) is breaking chain of command which is grounds for termination. When questioned by staff, ED explained that by speaking with licensing, staff are sabotaging him and the building. ED differentiated that staff could call the ombudsman but not the LPA. ED told staff they are only permitted to use the hotline but only after they’ve spoken with him and corporate.

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 5
Control Number 25-AS-20220829083205
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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On 8/17/2022, the Department conducted a site visit. The Department requested to interview Director Health and Wellness (DHW) in confidence. During the interview, ED interrupted and remained seated. This Department was unable to complete the interview due to the intrusion which is a violation of inspection authority regulations. Due to ED admitting that he was not familiar with the stipulations for Windchime of Chico, ED was unable to answer any questions or provide any documents to the Department. The Department requested DHW and Residential Service Director (RSD) to assist with the investigation as they were familiar with regulations and facility’s stipulations. ED became disruptive and left the office to shower and change his clothes then requested the Department come back later. ED then dismissed DHW and RSD from the room further preventing and delaying the Department. On 8/18/2022, DHW and RSD were pulled into a meeting with ED and Licensee representative from Milestone retirement to discuss citations and speaking with CCLD. At this time, DHW and RSD were told the ED had to be present for conversations with CCLD and they could not be alone with LPA or provide assistance to LPA.

On 8/26/2022, the Department learned RSD was terminated from their position and DHW was suspended then later terminated. 2 of 2 staff interviewed on 8/17/2022 were terminated. Both staff were floor supervisors leaving caregivers and med techs without a direct supervisor.

Allegation: Administrator yelled at staff in front of residents.

On 8/26/2022, near the 8PM med pass, assisted living side med techs requested ED to provide them with Title 22 regulations, allowing them to pass medications without a nurse present. Med techs questioned the ED due to their job description stating they pass medications under the direction of the DHW. Med techs were made aware the DHW was suspended but were not provided further direction. During this time staff took initiative to try and find their authority to pass medication in Title 22. Staff called multiple previous DHWs, ombudsman and other med techs to obtain the answer to no avail. Staff contacted former RSD who was on speaker and chose to record the conversation between staff and ED. In the recording, screaming can be heard between staff and ED. Staff can be heard requesting Title 22 and ED can be heard yelling, “just pass the (explicative) pills.” Per statements provided in the way of Declarations, a family member visiting a resident came to the med room to see what was taking place. At no time, is ED heard providing staff with Title 22. ED then left the facility and did not return until after med techs counted out medications at or around 9PM. Both med techs who requested Title 22 from ED were terminated.

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

Exit interview conducted.

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: 3 of 5
Control Number 25-AS-20220829083205
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
87705(c)(4)
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87705 Care of Persons with Dementia
(c )Licensees ... ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
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Administrator agrees to review Stipulation and Order and submit a letter of understanding to CCL by POC due date, 09/22/2022.
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This requirement is not met as evidenced by: Based on records review, observation, and interviews facility fails to meet staff ratios outlined in Stipulation and Order. Which poses an immediate health, safety, and personal right violation to residents in care.
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Type A
09/22/2022
Section Cited
CCR
87705(k)(7)
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87705 Care of Persons with Dementia (7) For each incident... The report shall be made by telephone no later than the next working day and in writing within seven calendar days.
This requirement is not met as evidenced by: Based on records review and interviews facility failed to report R1's elopment to CCL.
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Administrator agrees to read and review regulation section 87705 and submit a letter of understanding to CCL by POC due date, 09/22/2022.
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Which poses an immediate health, safety, and personal right violation 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: 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: 4 of 5
Control Number 25-AS-20220829083205
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
HSC
1569.37
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1569.37 Whistle blowers; retaliation
No licensee, or officer or employee of the licensee ... participated in the filing of a complaint, grievance, or a request for inspection with the department pursuant to this chapter, or has initiated or participated in the filing of a complaint, grievance… This requirement was not met as evidenced by:
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The facility agreed to cease all threats of retaliation to ensure staff who participate in investigation will be free of retaliation. A statement from the facility manager regarding these measures will ne submited to CCL by the POC due date, 09/22/2022.
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Based on interviews, Administrator terminated facility staff for assisting and providing CCL staff statement with open comlaint investigation. Which poses an immediate health, safety, and personal right violation 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: 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: 5 of 5