045001959-3-1-2023-25-AS-APEZ-CPKPXH-20230303104221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 03/01/2023
Date Signed: 03/01/2023 02:03:30 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/23/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221123114247

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: 66	DATE:	03/01/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive DIirector: Jacob Primeau		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility did not administer medications to residents.

INVESTIGATION FINDINGS:

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On 03/01/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 11/23/2022. 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 residents' physician’s report, service plans, Medication Administration Records (MAR), Freedom Hospice Care documents, and Incident Report.

Continue on page LIC 9099-C.

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: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

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-20221123114247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: WINDCHIME OF CHICO	FACILITY NUMBER: 045001959
	VISIT DATE: 03/01/2023

NARRATIVE

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According to complainant, residents' (R1 and R2) had missed their medication for more than a week. Medication room keeps running out of medication for residents in care. The facility submitted an unusual incident/injury report to CCL for review. Incident report indicated, R1 was noted by care staff to be laying with eyes open and face twitching on 11/17/2022. R1 was unable to speak clear sentences. R1 was admitted to the hospital for evaluation. R1 was discharged to a skilled nursing facility before returning to the community. According to R1's MAR, medications were not provided to resident from 11/17/2022 through 11/30/2022 due to being hospitalized.

R2's physician's report indicated R2 is unable to manage own medication. R2 is currently on hospice since 12/09/2021. The Department received and reviewed R2's MAR. MAR indicated R2's medications were on hold until medication is available for 5 medications on 01/15/2022 and 8 medications on 01/16/2022. On 11/09/2022 through 11/11/2022, 1 medication was not given to R2 due to medication unavailable. On 11/12/2022 through 11/16/2022, 4 medications were on hold due to medication unavailable. On 11/17/2022 through 11/22/2022, 3 medications were on hold until medication is available.

The Department interviewed four (4) facility staff. Interview statement received from S1 indicated, Freedom Hospice Care is responsible for certain medication refills for R2. S1 stated Med Techs are to call hospice or put in a refill request through Omnicare when there are 7-10 days of medications left. The Department requested records of medication request and communication with hospice records for review. Facility is unable to provide requested documents for review.

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: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 25-AS-20221123114247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 2525 NATOMAS PARK DR STE 270
SACRAMENTO, CA 95833

FACILITY NAME: WINDCHIME OF CHICO	FACILITY NUMBER: 045001959
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/08/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist	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, 03/8/2023.
	8 9 10 11 12 13 14	residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on documentation, facility failed to refill R2's medication from 11/15/2022 through 11/22/2022. 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: 03/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2023

LIC9099 (FAS) - (06/04)

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