045001959-3-9-2023-25-AS-APEZ-CPZT94-20230317143119

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 03/09/2023
Date Signed: 03/09/2023 02:42:28 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
11/09/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221109112922

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: 64	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director: Jacob Primeau		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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- Facility has inadequate brief supplies for residents.

INVESTIGATION FINDINGS:

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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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 7

Control Number 25-AS-20221109112922

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: 03/09/2023

NARRATIVE

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Allegation: Facility has inadequate brief supplies for residents. – Substantiated.

The Department received interview statements from four (4) facility staff (S). Interview statements received from all staff indicated the facility did not have adequate brief supplies for residents in care. Interview statement from S1 indicated, there were times when there were no briefs for residents in care and staff would grab briefs from other residents to use. S2 indicated, when facility would run out of brief supplies staff would notify management and they would purchase briefs the same day. S2 stated it also depends on how low the supplies are and how many briefs are in the last package. This will give the facility a cushion of three (3) days to purchase more briefs.

The facility provide the Department receipts for the purchase of briefs. The receipt provided for review indicated facility purchased a total of seven (7) package of briefs from CVS Pharmacy on 12/27/2022.

On 12/14/2022, LPA arrived at the facility unannounced to conduct complaint investigation. LPA toured the facility with S4 and observed resident’s (R5) bedroom. LPA observed R5’s bedroom has a strong urine odor. LPA interviewed R1 regarding brief supplies. Interview statement received from R1 indicated, R1 was out of briefs and only has the one R1 is currently wearing.

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 25-AS-20221109112922

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: 03/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/16/2023 Section Cited HSC 87625(b)(3)	1 2 3 4 5 6 7	87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are	1 2 3 4 5 6 7	Executive Director agrees to provide training on incontinence care with all care staff. Training subjects and staff sign in sheet to be sent to CCL by POC due date, 03/16/2023.
	8 9 10 11 12 13 14	kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as evidenced by: Based on interviews, facility failed to ensure R5’s room is free of urine odor. This poses a potential health and safety risk to resident in care.	8 9 10 11 12 13 14
Type B 03/16/2023 Section Cited CCR 87307(a)(3)	1 2 3 4 5 6 7	87307(a)(3) Personal Accommodations and Services (a) Living accommodations and grounds shall be related to the facility's function... The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the	1 2 3 4 5 6 7	Executive Director agrees to submit a written plan to ensure facility has adequate incontinence supplies for residents in care. ED is to submit plan to CCL by POC due date, 03/16/2023.
	8 9 10 11 12 13 14	following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: This requirement was not met as evidenced by: Based on interviews and documentation, facility failed to ensure residents have adequate incontinence supplies. This poses a potential health and safety risk to resident in care.	8 9 10 11 12 13 14

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
11/09/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221109112922

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: 64	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director: Jacob Primeau		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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- Facility food service for residents is inadequate.
- Staff is not keeping up with facility finances.

INVESTIGATION FINDINGS:

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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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 25-AS-20221109112922

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: 03/09/2023

NARRATIVE

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Allegation: Facility food service for residents is inadequate. – Unsubstantiated.

According to complainant, food deliveries have been interrupted due to nonpayment. The Department requested and received vendor ship invoice from the facility for review. According to the vendor ship invoice from 11/06/2022 through 11/13/2022, the facility is receiving food supplies from US. Foods. On 11/14/2022, the facility is received food supplies from another vendor, S & S Wholesale Produce. Interview statement received from Regional Culinary Specialist, Chad Bonsell indicated, the facility is not experiencing any food shortages. The facility is purchasing food from numerous vendors to ensure the quality of food is good. The facility is picking vendors based off of food quality.

On 11/17/2022, LPA arrived at the facility unannounced to conduct complaint investigation and interviewed a total of four (4) residents and three (3) facility staff. Interview statement received from four (4) residents were consistent. All residents stated food service for resident is adequate. Interview statement received from R1 stated, food service is good. The facility provides three (3) meals a day and snacks are provided upon request. Overall, R1 does not have any complaints about the food service. Interview statement received from R2 indicated, R2 is happy with the food service, however, believes the facility needs to hire more staff. R2 stated staff calls in sick a lot. R2 expressed the quality of the food is good and is overall happy with the food service. R4 stated, “I’m picky with food.” R4 indicated facility has been very accommodating with her food allergies and would substitute out certain foods. Interview statement received from staff (S1) indicated the facility is following the best standards when it comes to food service. S1 indicated food portion is not consistent. Memory care residents are receiving smaller portions compared to assisted living residents. S2 stated snacks are provided to memory care residents but assisted living residents has to request for snacks.

Allegation: Staff is not keeping up with facility finances. – Unsubstantiated.

According to complainant, the facility was in the process of repairing the AC in the Memory Care Unit but due to no payment it has not been repaired. The facility submitted climate energy solutions invoice of AC repair to the Department for review. On 07/14/2022, a unit was installed for replacement of mini split in kitchen for the amount of $5,400.00 and another unit was installed for installation of (3) air handler and (3) heat pump condenser for the amount of $43,500.00.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (323) 485-4915
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (209) 202-9552
LICENSING EVALUATOR SIGNATURE:	DATE: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 25-AS-20221109112922

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: 03/09/2023

NARRATIVE

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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.

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 7

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
11/09/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221109112922

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: 64	DATE:	03/09/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director: acob Primeau		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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- Facility A/C is in disrepair.

INVESTIGATION FINDINGS:

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On 03/09/2023, Licensing Program Analyst (LPA) Sarena Keosavang arrived at the facility unannounced to deliver final finding Community Care Licensing received on 11/09/2022. 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 (S), residents (R) in care, and obtained pertinent documents relevant to the complaint investigation such as, climate and energy solution invoice. According to complainant, the facility was in the process of repairing the AC in the Memory Care Unit but due to no payment it has not been repaired. The facility submitted climate energy solutions invoice of AC repair to the Department for review. On 07/14/2022, a unit was installed for replacement of mini split in kitchen for the amount of $5,400.00 and another unit was installed for installation of (3) air handler and (3) heat pump condenser for the amount of $43,500.00. This agency has investigated the complaint allegation above.

The Department have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

Exit interview conducted and report provided.

Unfounded

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: 03/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 7 of 7