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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 11/06/2023
Date Signed: 11/06/2023 04:53:29 PM


Document Has Been Signed on 11/06/2023 04:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:WINDCHIME OF CHICOFACILITY NUMBER:
045001959
ADMINISTRATOR:MOMO DUOAFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 63DATE:
11/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Office Manager- Jennifer CovingtonTIME COMPLETED:
05:00 PM
NARRATIVE
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On 11/6/2023, Licensing Program Analyst (LPA) Jaynae Boyles, arrived at the facility unannounced to conduct a 1-Year Required Annual Inspection. LPA met with Office Manager, Jennifer Covington and explained the purpose of the visit.

LPA Boyles and the Office Manager toured facility together to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms and resident restrooms. LPA observed each bathroom to have the necessary grab bars, non-skid flooring or shower chair, paper towels, and trash can with lids.

LPA observed the facility to be clean, in good repair and odor-free. LPA observed an activity calendar and activity materials, ie board games, puzzles, and books. The month activity calendar offers a variety of individual and group activities for residents to participate.

Facility has a 2-day perishable and a 7-day non-perishable amount of food. Hot water temperature was measured and within the required temperature range. LPA observed a weekly menu which offers a variety of health options for the residents.

LPA observed fire extinguishers, fire detectors, and carbon monoxide detectors throughout the facility which were last serviced in October of 2023.

LPA reviewed a total of six (6) residents' files and four (4) staff files. LPA observed residents to have postural supports, upon review of the resident file there was no order on file for the use of the postural supports. LPA observed one of six medical assessments to be incomplete and no tuberculosis test. LPA observed expired first aid for all staff files reviewed.

LPA observed the facility to have not completed the required amount emergency disaster dills within the last 12 months.

Deficiencies cited from Title 22 Regulations and or the California Health and Safety Code.


Several topics were discussed.

An exit interview was conducted, and Plans of Corrections were reviewed and developed collaboratively. A
copy of this report, LIC 809-D, and Appeal Rights were discussed and provided.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


Document Has Been Signed on 11/06/2023 04:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staff file reviews did not have the required first aid training which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Administrator will schdule first aid training for all staff. Furthermore, Administrator will ensure that all staff have the required first aid training.
Deficiency Dismissed
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of six resident file reviews filis not have a a completed tuberculosis test which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Administrator will have the resident tested for tuberculosis and ensure that all residents are tested before admission.
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: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 11/06/2023 04:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of four, emergency disaster drills were conducted within a 12 month period which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Administrator will develop an emergency disaster plan to ensure that emergency disaster drills occur quarterly , taking into account different emergency scenarios. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
Request Denied
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in three out of six review of client records did not have a medical order for postural supports in the file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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Adminstrator will ensure that residents with postural supports have a medical order within the file.
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: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 11/06/2023 04:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of six resident file reviews,one resident medical assessment was incomplete which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2023
Plan of Correction
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Adminstrator will ensure that the resident has a completed medical assessment. Furthemore, the adminstrator will ensure that all residents with dementia have updated medical assessments annually.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4