045001959-1-11-2023-25-AS-KHOS-CN8KVC-20230119071408

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 01/11/2023
Date Signed: 01/11/2023 01:58:18 PM

Unsubstantiated

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
09/01/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20220901133636

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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Facility did not provide 60 days for increase in fee.

INVESTIGATION FINDINGS:

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On 01/11/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final findings 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 was screened by facility staff and washed hands prior to entering the facility.

During the course of the investigation, the Department interviewed facility staff and obtained pertinent documents relevant to the complaint investigation, such as resident’s (R1) physician’s report, service plans, ledgers, and 60-day notice of annual increase.

Continue on page LIC 9099-C.

Unsubstantiated

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-20220901133636

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, R1’s responsible party (RP) received a copy of R1’s billing that indicated a change to Assisting Living services prorated back to 08/06/2022 through 08/31/2022. There was a prorate in service plan that did not exist. The service fee on the billing statement was different than the ones given on the service agreements completed in the past. Complainant’s concern is that the facility had changed R1’s service plan without notifying R1’s RP of changes in services.

According to R1’s July 2022 ledger, it indicates total charges is $5,312.50, which includes Assisted Living services for the amount of $822.50 and Assisted Living studio rent for $4,490.00. Ledger for the month of August 2022 indicated the same charges for Assisted Living services and studio rent.

According to R1’s ledger for the month of 09/01/2022 to 09/31/2022, it indicates the total charges for R1 is $10,024.52. The facility had prorated for the month of 08/06/2022 to 08/31/2022 for Assisted Living services for the amount of $1,505.00 and $822.50. New total fee for R1 is $8,072.42. According to R1’s service agreement completed on 08/18/2022, the service fee is $1,750.00 and per point charge is $70.00, which depends on R1’s score on assessment. According to R1’s service agreement completed on 08/24/2022, the service fee had decreased to $1,085.00 with a per point charge of $70.00. Interview statement received from ED indicated the facility had made errors on R1’s account and corrected the errors by crediting R1’s RP. ED stated the facility did not change R1’s service plan or made any changes to the services R1 was originally receiving.

On 07/29/2022, the facility notified R1’s RP with a 60-day notice of annual increase. The facility’s annual adjustment for this year is R1’s base rate before any applicable discounts or adjustments from $4,490.00 monthly to $4,850.00, which will be effective on 10/01/2022. According to R1’s ledger for the month of 09/01/2022, the total amount due is $5,818.75, which includes Assisted Living services for $4,850.00, Assisted Living services for $787.50, and a miscellaneous escort fee for $181.25.

The Department requested and reviewed R1’s service plan completed on 07/14/2022, 08/18/2022, 08/24/2022, and 10/20/2022. R1’s service plan conducted on 08/18/2022 and 08/24/2022 indicated no changes in R1’s service plan. On 10/20/2022, a care conference meeting was held to discuss R1’s ledger and updated/signed service plan. Present at the meeting were R1, R1’s RP, LPA Keosavang, ED, facility Nurse Alma Gomez, and Business Manager Jennifer Covington.

Due to the information above, CCL 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 with Executive Director, copy of report was provided via email.

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)

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