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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 02/16/2023
Date Signed: 02/16/2023 11:43:58 AM

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
02/13/2023 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 25-AS-20230213131349
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: DATE:
02/16/2023
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jacob Primea- Executive Director TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not following COVID-19 protocols.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 2/16/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannouned and met with Executive Director (ED), Jacob Primeau, to open complaint investigation. LPA wore N-95 mask and was screened by facility upon entry. During today’s visit, LPA toured the facility and conducted interviews with facility staff.

According to Complainant, there are COVID-19 positive residents in the Memory Care (MC) side. MC Med Tech (MT) goes to Assisted Living (AL) side to pass out medications on the first floor. Interview statement gathered from S1, confirmed a MC MT assisted in passing out medication in the AL side. LPA observed a bin in front of COVID-19 positive residents' room with PPE supplies such as, masks, gloves, gowns, face shields, booties, and PPE disposal garbage with lid. Interview statement from ED indicated, caregivers have designated areas due to caregivers providing direct care to residents. However, MT are only passing out medication and is not in the presence of residents for a long period of time. Interview statement received from S2 indicated, MTs are to perform MT duties unless there is an urgent situation that requires assistance with direct care. 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
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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