045001959-6-14-2023-59-AS-KHOS-CT6RTT-20230626131853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 06/14/2023
Date Signed: 06/14/2023 01:42:23 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, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/14/2023 and conducted by Evaluator Donna Gurriere

COMPLAINT CONTROL NUMBER: 59-AS-20230314172056

FACILITY NAME:	WINDCHIME OF CHICO		FACILITY NUMBER:	045001959
ADMINISTRATOR:	MOMO DUOA		FACILITY TYPE:	740
ADDRESS:	855 BRUCE RD		TELEPHONE:	(530) 566-1800
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	120	CENSUS: 62	DATE:	06/14/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Momo Duoa		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident’s medications are missing.
Facility storing forms that are out of date.

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 03/14/23. LPA Gurriere met with Momo Duoa, Administrator and explained the purpose of the visit.

Resident’s medication are missing.

During the interview process, the Health and Wellness Director was interviewed, and various documents were obtained and reviewed to include Physician’s Reports, Medication Administrator Records (MARs), medication notes, medication list and staff telephone numbers.

continued

Substantiated

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: 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 4

Control Number 59-AS-20230314172056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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) went between two weeks to nearly two months without some of his prescribed medications. It was also noted that the resident had two stays during that time period in the hospital. It was stated that the resident received services from Veterans Affairs (VA) and it was difficult to get the prescribed medications refilled. On 03/23/23 Sarena Keosavang, LPA obtained the records, which revealed that during the time period of 02/01/23 – 03/23/23, the facility medication log indicated that the resident did not have a supply of prescribed medications as follows:
Gabapentin
Take 1 Cap by mouth at each bedtime for chronic pain.
02/01/23 – 02/15/23 – On hold until medication is available.

Ensure Liquid Strawberry
Drink 237 ML by mouth three times daily
02/02/23 – 03/21/23 – On hold until medication is available.

Ciclopirox
Apply to affected areas bilateral feet and toenails twice daily.
02/01/23 – 03/23/23 – On hold until medication is available.

SF 5000 Plus 1.1% Cream
Brush with one thin ribbon to teeth twice daily.
02/01/23 – 02/28/23 – On hold until medication is available.

Ferrous Sulfate 325MG
Take one tablet by mouth twice daily to prevent iron deficiency.
03/03/23 – 03/20/22 – On hold until medication is available.

Ropinirole HCL 0.5MG
Take one tablet by mouth every day for Parkinson’s disease.
03/14/23 – 03/16/23 – On hold until medication is available.

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (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: 06/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20230314172056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WINDCHIME OF CHICO	FACILITY NUMBER: 045001959
	VISIT DATE: 06/14/2023

NARRATIVE

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The licensee did not have prescribed medications for a resident available for intake as required. 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.

Facility storing forms that are out of date.

During the interview process, the Health and Wellness Director was interviewed, and various documents were obtained and reviewed to include Physician’s Reports, Medication Administrator Records (MARs), medication notes, medication list and staff telephone numbers.

During the investigation process, it was indicated that residents did not have an updated Physician’s Report on file, as required for those residents that have dementia. Physician’s Reports are required to be updated yearly. On 03/23/23 Sarena Keosavang, LPA obtained seven Physician’s Reports for residents in the dementia unit. The records, indicated that seven of the reports were nearly at least two years overdue.

The licensee did not have Physician’s Reports for residents updated, as required. 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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (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: 06/13/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 59-AS-20230314172056

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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 A 06/15/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	Incidential and Medical - A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	The administrator agrees to ensure that resident's have their medications as required. The administrator shall develop a plan as how to avoid this type of deficiency in the future. The admistrator will submit the plan to the licensing agency.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not ensure that a resident had their medications available for intake, as prescribed by the physician. This poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 06/21/2023 Section Cited CCR 87705(c)(5)	1 2 3 4 5 6 7	Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment... Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.	1 2 3 4 5 6 7	The administrator agrees to ensure that residents' Physician's Report are up to date. The administrator agrees to update all of the dementia residents Physician's Reports, as required. Administrator shall submit a plan to the licensing agency.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and records review, the licensee did not ensure that the residents’ Physician Reports were updated, as required. This poses a potential health and safety risk to residents 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: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna Gurriere	TELEPHONE: (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: 06/13/2023

LIC9099 (FAS) - (06/04)

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