045001959-2-21-2024-59-AS-KHOS-D3GK69-20240318073711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:09:23 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
12/21/2023 and conducted by Evaluator Jaynae Boyles

COMPLAINT CONTROL NUMBER: 59-AS-20231221162919

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:	01:05 PM
MET WITH:	Administrator- Lisa Fennel		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not distribute residents' medications as prescribed.

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 the executive director. The purpose of this visit is to deliver the results of a complaint investigation.
During the interview process, LPA interviewed seven staff members and the resident care director. During the review of records, LPA reviewed the files of one resident, including incident reports, and medical records. Of the staff interviewed, the majority of staff indicated that medication errors are not often, and when they occur, it is reported to management. Of the staff interviewed, all indicated that when distributing medications for residents, staff follow the medication orders listed in the electronic Medication Administrative Record (MAR).
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.
An exit interview was conducted. A copy of the report was provided to the executive director.

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 1