045001959-5-9-2023-25-AS-APEZ-CRXNJJ-20230518103024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 05/09/2023
Date Signed: 05/09/2023 10:45:23 AM

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
02/22/2023 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 25-AS-20230222085422

FACILITY NAME:	WINDCHIME OF CHICO		FACILITY NUMBER:	045001959
ADMINISTRATOR:	JACOB PRIMEAU		FACILITY TYPE:	740
ADDRESS:	855 BRUCE RD		TELEPHONE:	(530) 566-1800
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	120	CENSUS: 58	DATE:	05/09/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Momo Duoa		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility does not have enough staff to meet the needs of residents in care.

INVESTIGATION FINDINGS:

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On 05/09/23, Licensing Program Analyst (LPA) Donna Gurriere arrived at the facility unannounced to deliver final finding Community Care Licensing received on 2/22/2023. 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, residents’ (R1, R2, and R3) physician’s report, medication administration records (MAR), medication list and medication orders for review.

Continued

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (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)

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Control Number 25-AS-20230222085422

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: Facility does not have enough staff to meet the needs of residents in care. Unsubstantiated.

According to complainant, there were four (4) care staff scheduled to provide care and supervision to residents in care on 02/20/2023. A Med Tech was out on leave and the replacement Med Tec had called out. A care staff trained as a Med Tech was reassigned to pass out medication leaving one (1) caregiver for the assisted living side. Memory care unit had two (2) care staff one of which is floating so assisted living unit side doesn’t fall behind, but memory care residents are being neglected due to the scheduling. Med Tech from memory care side is not able to assist residents with care and assisted living Med Tech refuses to stop their pass to help out. Management refuse to be in before their scheduled time.

The facility is currently on probation. According to Stipulation and Order adopted by the Department on 06/08/2022, Respondents shall strictly adhere to the resident and staff ratios and shall ensure that the facility is sufficiently staffed with caregivers to meet the needs of residents in care. Additionally, Respondents shall ensure that the facility is staff with the following minimum staff. The Memory Care Unit shall maintain a staff to resident ratio of 1:6 or more as needed to sure that residents’ needs are met. The Assisted Living Unit shall maintain a staff to resident ratio of 1:10 or more as needed to sure that residents’ needs are met. The Memory Care Unit shall maintain a staff to resident ratio of 1:11 or more as needed to ensure that residents’ needs are met during the right-on-call (“NOC”) shift. The Assisted Living Unit shall maintain a staff to resident ratio of 1:16 or more as needed to ensure that residents’ needs are met during the NOC shift. Only one (1) caregiver may be deemed a “floater” during the entirety of the NOC shift and be counted in the ratio of both the Memory Care Unit and Assisted Living for that shift. Respondents shall ensure that the caregiving staff’s other duties do not distract from caregiving, and that working in the capacity of caregiver does not distract from the staff’s primary duties. A Med Tech shall not be included in the direct care ratio when they are performing Med Tech duties.

continued

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (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)

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Control Number 25-AS-20230222085422

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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The Department interviewed a total of four (4) facility staff (S). Interview statement received from S1 indicated, the facility would schedule 2 Med Techs and about 3-4 caregivers on both assisted living and memory care side. Interview statement received from S2 indicated, there was one (1) Med Tech, one (1) caregiver in the memory care side and three (3) caregivers in the assisted living side that was present at the facility on 04/20/2022. The facility had moved caregivers around where they were needed. NOC shift staff were asked to work overtime to assist residents. The facility had reached out to agency and requested for additional staff. Two (2) agency staff arrived at the facility at 8 AM to fill in. S2 stated staff were able to meet the needs of residents in care, but care was delayed.

The Department requested and reviewed the facility’s staff schedules. The facility’s census in February of 2023 is 61, 42 residents in assisted living side and 19 residents in memory care side. According to staff schedules, a total of 5 caregivers and 2 Med Tech were scheduled to work. Interview statement received from Executive Director, Jacob Primeau, indicated the facility has sufficient staff to meet the needs of residents in care. ED stated during the storm staff were having trouble getting to work due to the snow. The facility had agency staff cover shifts to meet the staffing ratios.

The Department requested and reviewed R1, R2, and R3’s medication list and medication administration records (MAR). Medications for R1, R2, and R3 were given and found no discrepancies.

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. Report was prepared by LPA Sabrina Keosavang. LPA Donna Gurriere presented the report to the administrator this date.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (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)

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