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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 11/08/2023
Date Signed: 11/08/2023 09:18:13 AM


Document Has Been Signed on 11/08/2023 09:18 AM - 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:
11/08/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Executive Director- Momo Duoa TIME COMPLETED:
09:30 AM
NARRATIVE
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LPA Boyles and Alvia arrived at the facility unannounced to conduct a case management meeting regarding the posting of the stipulation order.

LPA observed that the Stipulation was not posted as required in the Stipulation and Waiver section C.
LPA observed that there was a poster stating it was available upon request. However, this is not in compliance with the requirements of the Stipulation Order.

The following deficiencies were cited per Title 22 of the California Code of Regulation (See LIC 809D). 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 dates; civil penalties may be assessed.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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 2


Document Has Been Signed on 11/08/2023 09:18 AM - 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: 11/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/09/2023
Section Cited
HSC
1569.38

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1569.38-Posting of licensing reports; disclosure to new residents-(e) the licensed residential care facility shall also post a written notice, in at least 14-point type, in a conspicuous location in the facility, ... where the facility license is posted, or any other easily accessible location in the facility.
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Licensee agrees to provide a plan of correction to LPA after consulting with Milestone. Licensee agrees to discuss and provide the plan to LPA by 10 AM on 11/09/2023.
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This requirement is not met as evidenced by: Based upon interview and observation, the Licensee failed to post the Stipulation Waiver and Order.
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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: 11/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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