045001959-3-9-2023-25-AS-APEZ-CQ4T4F-20230320142354

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 03/09/2023
Date Signed: 03/09/2023 02:24:20 PM

Unsubstantiated

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
12/19/2022 and conducted by Evaluator Sarena Keosavang

PUBLIC

COMPLAINT CONTROL NUMBER: 25-AS-20221219104021

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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Staff are not logging residents medication on the MAR.

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 12/19/2022. 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, resident’s (R1) physician’s report, service plan, medication list, and medication administrator record.

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: 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)

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Control Number 25-AS-20221219104021

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: Staff are not logging resident’s medication on the MAR. – Unsubstantiated.

According to complainant, R1 moved into the community in the beginning of December. R1’s medications were not inputted into the MAR. As of 12/15/2022, medications are pending but haven’t been approved.

According to R1’s physician’s report, R1 is unable to administer own prescription medications and store own medications. The Department requested and received R1’s MAR for December of 2022. According to the MAR, there are four (4) medications that were not given to R1 on 12/15/2022. All four (4) medications were effective on 12/15/2022.

Interview statement received from Director of Sales and Marketing indicated, R1 was discharge from a skilled nursing facility. Skilled nursing facility did not discharge R1 with medications. R1’s responsible party had provided the facility with all the medications they had for R1 at that time. On 12/12/2022, the facility requested for R1’s medications through Omnicare. Fax cover page provided to the Department for review.

Interview statement received from Med Tech indicated, R1 was a new resident and the facility were having issues getting their hands on the medication due to skilled nursing discharging R1 without medications. Med Tech stated the facility were trying to communicate and get medication filled on the weekend and it’s difficult to get medications on the weekend. The medications were requested through Omnicare. Interview statement received from R1’s POA indicated R1's medications were dropped off at the facility.

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: 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)

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