045001959-2-21-2024-59-AS-KHOS-D32NK2-20240304093115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:26:15 PM

Unsubstantiated

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
01/16/2024 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20240116130708

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: 53	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Administrator- Losa Fennel		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Neglect/Lack of Supervision

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

02/21/2024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with Executive Director. The purpose of this visit is to deliver the results of a complaint investigation.
During the interview process, the executive director and witnesses were interviewed.
During the review of records, LPA reviewed the files of one resident, including incident reports, medical records, admissions agreement.
LPA investigated the allegation, “Neglect/Lack of Supervision”. Of the eight staff that were interviewed all indicated that they are regularly able to meet the needs of the residents and often help others to ensure that all the needs of the residents are met in a timely manner. It was reported that the staff are meeting the residents’ activities of daily living to include bathing, dressing, getting in and out of bed or a chair, walking, using the toilet and eating.
Although the allegations 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. Exit interview conducted, copy of this report, 9099A and appeal rights left at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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 3

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
01/16/2024 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20240116130708

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: 53	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Administrator- Losa Fennel		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility gave resident another resident’s medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

02/21/2024 Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with the Executive Director. The purpose of this visit is to deliver the results of a complaint investigation.
During the interview process, the executive director and witnesses were interviewed.
During the review of records, LPA reviewed the files of one resident, including incident reports, medical records, admissions agreement. LPA investigated the allegation, “Facility gave resident another resident’s medication.” During the investigation, the Administrator reported that the resident (R1) was given the wrong medication by the med tech that was working the day of the incident. The administrator reported that (R1) was taken to the hospital for observation due to the medication error. The resident was returned to the facility without any incident or complications.
Based on interviews and evidence obtained during the investigation, 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 LIC9099D. Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to the administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 59-AS-20240116130708

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: 02/21/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/21/2024 Section Cited CCR 80075(b)(5)(B)	1 2 3 4 5 6 7	80075 Health Related Services (b)(5)(B) - Once ordered by the physician the medication is given according to the physician's directions. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator agreed to submit a self-certification in regard to providing medication training for all staff regarding medication administration and submit proof to LPA by POC date- 03/06/2024.
	8 9 10 11 12 13 14	Based on records reviewed and interviews, R1 was given the wrong medications in error. These medications were not ordered by R1s physician, which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	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 Crocker	TELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae Boyles	TELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

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