<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 12/14/2022
Date Signed: 12/14/2022 11:43:31 AM


Document Has Been Signed on 12/14/2022 11:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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: 57DATE:
12/14/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director- Jacob PrimeauTIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On December 14, 2022, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to conduct a Case Management visit. LPA met with Executive Director, Jacob Primeau, and explained the purpose of the visit. LPA wore a surgical mask and were screened by facility staff prior to entering the facility.

The purpose of the visit was to follow-up on an unusual incident/injury report that was sent to Community Care Licensing (CCL) on 12/13/2022. The report indicates that Med-Tech noted resident (R1) has a skin tear on right hand, one stage II wound on right buttock, one stage II on left buttock, and open wound on coccyx as well as an abscess on soft palate of mouth. The facility notified R1's Primary Care Physician (PCP) and R1's POA. PCP gave order to sent R1 out to the hospital for possible abscess drainage. R1 transported to the hospital. R1 on alert charting per facility protocol. Care service plan is updated per policy and protocol.

LPA interviewed ED regarding the report. R1 has not been discharged from the hospital. LPA requested for R1's physician report, needs and services plan, and discharge medical documents after discharge from hospital.

At this time, deficiencies are not being cited.

Exit interviewed conducted and report provided.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:
DATE: 12/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1