<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 07/11/2023
Date Signed: 07/11/2023 10:32:59 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, 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
02/06/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20230206114544
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: 60DATE:
07/11/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Momo DuoaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not clean the resident’s room.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/11/23, Donna Gurriere and Jaynae Boyles, Licensing Program Analysts (LPAs) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 02/06/23. LPA Gurriere met with Momo Duoa, Administrator and explained the purpose of the visit.

Staff did not clean the resident’s room.
During the interview process, 11 staff persons were interviewed to include, the administrator, the operations specialist, the maintenance director, housekeepers, care providers and medication technicians. Various documents were obtained and reviewed to include Physicians Reports, Photos, Service Plan, Service Agreement, Medication Administrator Records (MARs), Pain Medication Orders, Preplacement Appraisal, Residence Care Agreement, Visitor Log, Progress Notes, Personal Property and Valuables Document, Menus, and the resident’s Death Report. The resident (Resident 1) was not interviewed as he has since passed away.

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: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
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 8
Control Number 25-AS-20230206114544
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: 07/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
continued

During the investigation process, the staff reported that the resident wanted his room cleaned one time per week, or every other week. On 01/27/23 the resident’s Service Agreement was updated, and it stated that the resident needed daily bed making services and daily housekeeping. It was reported that the room was messy and that the resident stored food, paint, and art supplies in his room. It was stated that when the resident became incontinent, the carpets were dirty and had urine stains on them. Carpets were not maintained and cleaned, 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 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: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 25-AS-20230206114544
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: 07/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2023
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
Maintenance and Operation – The facility shall be clean, safe, sanitary and in good repair at all times.
This requirement was not met as evidenced by: Based on interviews, the licensee did not ensure that the resident’s carpets were clean, safe, sanitary and in good repair at all times.
1
2
3
4
5
6
7
The administrator agrees to identify the carpets that are in need of cleaning and provide a carpet cleaning schedule to the licensing agency to ensure that resident carpets are clean and maintained. Carpet cleaning schedule to be provided to the licensing agency by 07/25/23.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 07/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
02/06/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 25-AS-20230206114544

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: 60DATE:
07/11/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Momo DuoaTIME COMPLETED:
10:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff stole resident’s personal belongings.
Resident was financially abused while in care by an adult.
Staff did not provide resident’s medication as prescribed.
Staff did not ensure that the resident had the appropriate amount of fluids while in care.
Resident was left in soiled clothing.
Staff did not provide adequate food service to resident in care.
Staff did not provide adequate laundry service.
Resident was not provided linens for bed.
Resident was not provided towels to properly clean self.
Resident was not provided showering as needed.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/11/23 Donna Gurriere and Jaynae Boyles, Licensing Program Analysts (LPAs) arrived at the facility unannounced to deliver final findings regarding a complaint that was received on 02/06/23. LPA Gurriere met with Momo Duoa, Administrator and explained the purpose of the visit.

Staff stole resident’s personal belongings.
During the interview process, 11 staff persons were interviewed to include, the administrator, the operations specialist, the maintenance director, housekeepers, care providers and medication technicians. Various documents were obtained and reviewed to include Physicians Reports, Photos, Service Plan, Service Agreement, Medication Administrator Records (MARs), Pain Medication Orders, Preplacement Appraisal, Residence Care Agreement, Visitor Log, Progress Notes, Personal Property and Valuables Document, Menus, and the resident’s Death Report. The resident (Resident 1) was not interviewed as he has since passed away.

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: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 25-AS-20230206114544
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: 07/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
continued

During the investigation process, it was reported that items were missing from the resident’s room, which included personal checks and a type of over-the-counter medication. As mentioned, 11 staff persons were interviewed and staff reported that they were not aware of checks or medication being stolen. It was noted in the progress notes that a family member made the allegation; therefore, a staff person contacted the Chico Police Department and reported the incident to an officer. The resident’s family member stated that the police department have a record of the complaint and will conduct a follow-up.

Resident was financially abused while in care by an adult.
During the investigation process, it was reported by the resident’s family that an adult female came to the facility and provided the resident with handwritten cards and painted rocks. It was reported that the adult female stole the resident’s credit card and used the card. A report was filed with the Chico Police Department, and it was reported by the resident’s family member that they are to investigate. As mentioned, 11 staff persons were interviewed and none of the staff persons could recall a female adult by the name that was provided that came to the facility to meet with the resident. The “visitor’s log” was reviewed from the time period of 05/2022 through 02/2023 and there was not a name that matched the adult female name entered into the visitor’s log. It is noted that the resident resided at the facility for approximately seven years, and it was reported that the resident had many visitors.

Staff did not provide resident’s medication as prescribed.
During the investigation process, a review of the Medication Administration Records (MARs) indicated that there was a scheduled pain medication prescribed in that the resident was to take the pain medication two times a day. Once the resident began experiencing additional pain, the order was changed to Pro Rata Need (PRN) prescription, meaning it was on an as needed basis. Staff indicated that once the prescription order was clarified as a PRN, the resident was able to communicate when he needed pain medication. On 06/14/23 LPA Gurriere went to the facility to review resident medications in the facility’s medications room and the medications were in order.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 25-AS-20230206114544
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: 07/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
continued

Staff did not ensure that the resident had the appropriate amount of fluids while in care.
During the investigation process, staff persons were interviewed, and they indicated that the resident was very independent with eating and drinking until he went on hospice care. The staff stated that the resident went on hospice and quickly, within a period of five days passed away. Care staff indicated that during the resident’s hospice care, the resident was provided oral mouth swabs in an effort to provide moisture and to keep the resident hydrated, as it was reported that the resident had a hard time swallowing.

Resident was left in soiled clothing.
During the investigation process, staff persons were interviewed, and they reported that the resident was independent in all of his daily activities, which included changing his clothes and showering. However, on 01/27/23 when the resident went on hospice, the resident’s Service Agreement stated that the resident needed physical assistance during toileting and/or incontinence care. The staff reported that once the resident went on hospice, they and the hospice nurses provided the resident with changing and he received bed baths.

Staff did not provide adequate food service to resident in care.
During the investigation process, a copy of the menu was received and reviewed for the months of November 2022 through February 2023. Staff reported that again the resident was very independent and that at times the resident would eat at the facility and at other times he would go out for his meals. Overall, the menu that was reviewed had the appropriate amount of nutrition. Staff reported that once the resident went on hospice, he declined rapidly and did not want his meals.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 25-AS-20230206114544
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: 07/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
continued

Staff did not provide adequate laundry service.
During the investigation process, staff persons were interviewed and stated that the resident’s laundry was laundered two times per week and more frequently when asked. Most staff stated that they were unaware of the allegation.

Resident was not provided linens for bed.
Resident was not provided towels to properly clean self.
During the investigation process, the administrator advised and provided a letter dated 11/30/22 that effective 01/01/23, the facility would be discontinuing their current linen service. Services included providing bed sheets and towels. It was requested in the letter that the family purchase the items and if they could not get the items, due to a lack of time, then the facility would purchase linens for residents and bill back to their account. On 01/27/13 the resident’s Service Agreement was updated, and it states that Linen Laundry included in basic housekeeping package: Provided weekly by the community.

The regulations state, that the resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of clean linens… (regulation continues).

Staff were interviewed and nearly all stated that they were not aware of the resident not having enough linens to include bed sheets and towels. The housekeeper indicated that the facility does have additional stock in place, as needed.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 25-AS-20230206114544
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: 07/11/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
continued

Resident was not provided showering as needed.
During the investigation process, the staff reported that initially the resident was independent to take his showers; however, it was stated that once the resident went on hospice, the resident declined quickly. It was stated by staff that they were able to provide bed baths two times a week, with additional baths provided by the hospice nurses.

Although the above allegations mentioned may have happened, or are valid, there is not a preponderance of evidence to prove that the alleged violations 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: 07/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8