045001959-1-11-2023-25-AS-KHOS-CN8KH9-20230119065444

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 01/11/2023
Date Signed: 01/11/2023 01:53:16 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 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-20220829095113

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: 59	DATE:	01/11/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Executive Director, Jacob Primeau		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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- Multiple residents not administered medication as prescribed.

INVESTIGATION FINDINGS:

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On 01/11/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 08/29/2022. LPA met with Executive Director, Jacob Primeau and explained the purpose of the visit. LPA ensured the following Personal Protective Equipment (PPE) was worn surgical mask. LPA were screened by facility staff and washed hands prior to entering the facility.

During the course of investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complaint investigation such as, interview statements from relevant parties, resident’s (R1) physician report, medication list, medical records medications, medication administration records (MAR), Omnicare communication, physician /healthcare provider communication form, and service agreement.

Continue on page LIC-9099C.

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: 01/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

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-20220829095113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WINDCHIME OF CHICO	FACILITY NUMBER: 045001959
	VISIT DATE: 01/11/2023

NARRATIVE

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According to complainant, forty-eight (48) residents were not administered medications on 08/26/2022 and 08/27/2022. The Department requested and reviewed ten (10) residents’ MAR. According to the MAR, R3-R9 were administered their medications.

On 08/31/2022, LPA Keosavang arrived at the facility to conduct complaint investigation. LPA met with R1’s responsible party (RP) and gathered interview statement. R1’s RP indicated there was a doctor’s order to discontinue one of R1’s medication, (Losartan Potassium) on 08/30/2022. RP stated the facility received the order on 08/31/2022. There was a change in order which the facility’s Med-Tech were notified and a fax was sent to the facility of the changes. Med-Tech notified RP that they had to wait to input it in their system. RP indicated R1’s blood pressure is too low and the medication that was discontinued causes R1’s blood pressure to decrease.

The Department received and reviewed R1’s doctor’s order for Losartan Potassium. According to the Doctor’s order, it states to stop Losartan Potassium on 08/30/2022 at 11:35 AM. According to R1’s MAR, Losartan Potassium was provided to R1 on 08/30/2022 and 08/21/2022.

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: 01/11/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 25-AS-20220829095113

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CHICO - RESIDENTIAL, 520 COHASSET RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WINDCHIME OF CHICO	FACILITY NUMBER: 045001959
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/18/2023 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:	1 2 3 4 5 6 7	Executive Director agrees to conducted training on medication and provide CCL proof of training. ED is to include topics and staff must sign off on the training. ED is to submit staff training to CCL by POC due date, 01/18/2023.
	8 9 10 11 12 13 14	(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by: Based on documentation review facility staff administered suspended medication to R1. This poses an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 01/11/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2023

LIC9099 (FAS) - (06/04)

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