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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 05/09/2023
Date Signed: 05/09/2023 10:36:14 AM

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
11/16/2022 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20221116111536
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: 58DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Momo DuoaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff do not address a resident's change in health condition.
INVESTIGATION FINDINGS:
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On 05/09/23, Licensing Program Analyst (LPA) Donna Gurriere arrived at the facility unannounced to deliver final findings Community Care Licensing received on 12/28/2022. LPA met with Executive Director, Momo Duoa, and explained the purpose of the visit.

During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) face sheet, physician’s report, care plan, and appraisal.

Continued
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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-20221116111536
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: 05/09/2023
NARRATIVE
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Allegation: Staff do not address a resident’s change in health condition. – Substantiated

The Department received and reviewed R1’s physician’s report. R1’s physician’s report was completed on 06/03/2016. According to R1’s physician’s report, R1 is able to bathe, dress, groom, feed, and care for own toileting needs. R1 is unable to administer own medications and PRN medications. R1 is able to independently transfer to and from bed. R1 is considered ambulatory. The facility submitted R1’s service plan for review. Effective on 08/06/2022, R1 needs assistance with physical transferring into and out of wheelchair. R1’s physician’s report and service plan contradict one another. A person who is unable to leave a building unassisted under emergency conditions is considered non-ambulatory. It includes any person who is unable, or likely to be unable, to physically and mentally respond to a sensory sign approved by the State Fire Marshal, or to an oral instruction relating to fire danger, and/or a person who depend upon mechanical aids such as crutches, walkers, and wheelchairs. R1’s physician’s report indicated, has mild cognitive impairment. The facility did not ensure R1’s medical assessment was updated.

The Department interviewed a total of seven (7) facility staff (S). Interview statement received from S2 indicated, R1 is not independent. R1 is very incontinence and has developed rashes that are getting worse. Interview statement received from S1 and S4 indicated, R1 needs a higher level of care. According to R1’s service plan, R1 is considered total incontinence which was effective on 07/30/2019. Staff would assist R1 to the restroom in the morning, before meals, before bedtime, and as needed. R1 also depends on briefs. Interview statement received from R1’s responsible party (RP) indicated, prior to R1 being admitted to Windchime of Chico R1 was not incontinence and did not depend on a wheelchair/walker. RP stated R1 has declined and needs a higher level of care. RP stated R1 is considered a fall risk and had multiple falls at the facility.

The Department received progress notes for R1 from the facility to review. On 04/10/2023, Director of Health and Wellness (DHW) attempted to reach R1’s power of attorney (POA) to notify POA that R1 does not have a current PCP. The PCP the facility has listed is no longer R1’s PCP. R1 had medications that no longer have valid refill orders and Omnicare is not able to fill. Facility has not received a response from R1’s POA. On 04/14/2023, DHW made a second attempt to reach POA. There have been multiple unsuccessful attempts to get in contact with POA. Voicemails have been left with a call back number and no returned call has been received.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 25-AS-20221116111536
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: 05/09/2023
NARRATIVE
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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. Report was prepared by LPA Sabrina Keosavang. LPA Donna Gurriere presented the report to the administrator this date.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 25-AS-20221116111536
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: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2023
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...
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Executive Director agrees to provide training for all direct care and administrative staff in the proper observation of residents. The training will be conducted by a STATE APPROVED VENDOR. Administrator will schedule the training and provide CCL with the date of the scheduled training and contact information for the trainer as the POC.
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This requirement was not met as evidenced by: Based on interviews and records review, the facility failed to ensure R1 was observed for changes in condition. This poses an immediate health, safety and personal rights risk to residents in care.
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Plan of correction shall be submitted to Sabrina Keosavang, LPA.
Type B
05/16/2023
Section Cited
CCR
87458(c)
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Medical Assessment: The licensee shall obtain an updated medical assessment when required by the Department.
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Executive Director agrees to obtain updated LIC 602 for R1. Facility is to submit updated LIC 602 to CCL for review by POC due date.
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This requirement was not met as evidenced by: Based on interviews and records review, R1’s LIC 602 was completed in 2016. Facility failed to obtain an updated LIC 602 for R1. This poses a potential health and safety risk to resident in care.
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Plan of correction shall be submitted to Sabrina Keosavang, LPA.
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: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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
11/16/2022 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20221116111536

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: 58DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Momo DuoaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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2
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Resident is left soiled for an extended period of time.
Lack of care and supervision.
INVESTIGATION FINDINGS:
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On 05/09/23, Licensing Program Analyst (LPA) Donna Gurriere arrived at the facility unannounced to deliver final findings Community Care Licensing received on 12/28/2022. LPA met with Executive Director, Momo Duoa, and explained the purpose of the visit.

During the course of investigation, the Department interviewed residents, facility staff, and obtained pertinent documents relevant to the complaint investigation such as, resident’s (R1) face sheet, physician’s report, care plan, appraisal, and call logs.

Continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 25-AS-20221116111536
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: 05/09/2023
NARRATIVE
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Allegation: Resident is left soiled for an extended periods of time. – Unsubstantiated.

The Department received and reviewed R1’s physician’s report. R1’s physician’s report was completed on 06/03/2016. According to R1’s physician’s report, R1 is able to care for own toileting needs. According to R1’s service plan, R1 is total incontinence and may refuse to allow care partners to assist R1 when brief needs to be changed. Staff are to check on R1 halfway through the NOC shift. Requests nighttime checks at least once in the night. R1 is at risk of falls and requires increased monitoring.

On 11/17/2022, the Department interviewed a total of seven (7) facility staff. Interview statement received from staff (S1) indicated, R1 is able to use the restroom unassisted. There is a commode located in R1’s room right next to the bed for R1 to use. S1 stated R1 would urinate in bed on multiple occasions and would often use call button for assistance. Interview statement received from S2 indicated, S2 has observed R1 completed soaked in urine. The commode in R1’s room needs to be emptied constantly. S2 stated R1 often urinates on the floor. Interview statement received from S3 and S4 indicated, they have not observed R1 left in soiled for an extended period of time. S5 stated R1 refuses to ambulate to the restroom and would urinate all over R1’s room. Interview statement received from S6 and S7 indicated, R1 does not need assistance with changing briefs and is capable of doing it independently.

Interview statement received from ED indicated, it became apparent that R1’s incontinence issues are related to R1 being unwilling to ambulate to the restroom. The recommendation of a catheter was suggested from a care staff who were unaware of the legal and regulatory expectation warranting the implementation of catheters. Director of Health and Wellness (DHW) was able to communicate the expectations to members of the care staff and enlighten them on the protocols of effectively supporting R1. R1 does not need a catheter, as R1 is able to void independently. Interview statement received from R1’s RP indicated, R1 is incontinence and requires staff to assist R1 in changing briefs every hour. R1 depends on briefs and would urinate in it then sit there which resulted in rashes and UTI.

Continued

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 25-AS-20221116111536
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: 05/09/2023
NARRATIVE
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Allegation: Lack of care and supervision. – Unsubstantiated.

The Department interviewed a total of seven (7) facility staff, ED, and R1’s RP. In addition, the Department obtained and reviewed, staffing schedule, R1’s physician’s report, service plan, and appraisal. The Department was unable to determine whether R1 was left in soiled for an extend period of time resulted of a lack of care and supervision or if it was due to R1 requiring a higher level of care.

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.

An exit interview was conducted, and a copy of the report left at the facility. Report was prepared by LPA Sabrina Keosavang. LPA Donna Gurriere presented the report to the administrator this date.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7