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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 06/14/2023
Date Signed: 06/14/2023 01:14:13 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
12/28/2022 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20221228092525
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: 62DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Momo DuoaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility staff are retaining a resident requiring a higher level of care.
INVESTIGATION FINDINGS:
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On 06/14/2023, Donna Gurriere and Rebecca Knight, Licensing Program Analysts (LPAs) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 12/28/22. LPA Gurriere and Knight met with Momo Duoa, Administrator and explained the purpose of the visit.

Facility staff are retaining a resident requiring a higher level of care.

During the interview process, the Health and Wellness director and five staff persons, were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Service Plan, Medication Administrator Records (MARs), incident reports, communication forms, and staff telephone numbers.

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: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
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 5
Control Number 25-AS-20221228092525
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: 06/14/2023
NARRATIVE
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During the investigation process, it was indicated that a resident (Resident 1) was having aggressive behavioral issues towards other residents. The behavioral issues were noted in the resident’s log and also reported on incident reports. The resident resided at the facility from 08/04/21 until 04/23/23.

It was reported that the resident displayed frequent disruptive behaviors that required monitoring and interventions. Behaviors to other residents, (census of approximately 17 residents), were reported to include: Hitting them with her walker, hair pulling, outbursts of rage, yelling in their faces, grabbing a resident by his cheeks, taking their food, and calling them names. It was reported that other residents were afraid of the resident, which caused tension, frustration, and at times, residents had to be separated from her.

The staff could not ensure the safety of other residents’ well being due to the resident’s outbursts and behaviors towards them within the community. All residents residing in the facility shall be accorded personal rights to include dignity in their personal relationships with staff, residents, and other persons. In addition, residents shall be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.

Based on investigation observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be Substantiated. California Code of Regulations, (Title 22), is being cited on the attached LIC 9099D.

Appeal Rights were explained and provided to the facility representative listed above and an exit interview was conducted. If any of the cited deficiencies are not corrected by the noted due date; civil penalties may be assessed.

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

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 25-AS-20221228092525
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: 06/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/22/2023
Section Cited
CCR
87468.1(a)(1)(2
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Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded dignity in their personal relationships with staff, residents, and other persons. To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
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Administrator agrees to ensure the safety of other residents in the facility. Administrator shall submit a plan of correction to the licensing agency.
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This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not ensure the personal rights of other residents in the community. This poses a potential health and safety risk to residents in care.
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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: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/28/2022 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20221228092525

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: DATE:
06/14/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Momo DuoaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not providing a resident adequate care and supervision.
INVESTIGATION FINDINGS:
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3
4
5
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On 06/14/2023, Donna Gurriere and Rebecca Knight, Licensing Program Analysts (LPAs) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 12/28/22. LPA Gurriere met with Momo Duoa, Administrator and explained the purpose of the visit.

Facility staff are not providing a resident adequate care and supervision.

During the interview process, the Health and Wellness director, and five staff persons, were interviewed. Various documents were obtained and reviewed to include Physicians Reports, Admission Agreements, Service Plan, Medication Administrator Records (MARs), incident reports, communication forms, and staffing telephone numbers.


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: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20221228092525
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: 06/14/2023
NARRATIVE
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During the investigation process, it was indicated that a resident (Resident 1) was having aggressive behavioral issues towards other residents. The behavioral issues were noted in the resident’s log and also reported on incident reports. The resident resided at the facility from 08/04/21 until 04/23/23.

It was reported that the resident displayed frequent disruptive behaviors that required monitoring and interventions. Behaviors to other residents, (approximately census of 17 residents), were reported to include: Hitting them with her walker, hair pulling, outbursts of rage, yelling in their faces, grabbing a resident by his cheeks, taking their food, and calling them names. It was reported that other residents were afraid of the resident, which caused tension, frustration, and at times, residents had to be separated from her.

Interviews by staff indicated that the staff did everything that they could possibly do, to manage the resident’s maladaptive behaviors. Staff were in contact with the resident’s physician in an effort to have a psychiatric exam and to adjust the resident’s medications. On 12/20/22 a physician approved to adjust the resident’s medication in an effort to help regulate her mood and behaviors.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the findings are Unsubstantiated.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5