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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 11/09/2020
Date Signed: 11/09/2020 02:22:35 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/27/2020 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20200227171701
FACILITY NAME:WINDCHIME OF CHICOFACILITY NUMBER:
045001959
ADMINISTRATOR:DAVID JR, RICKYFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 57DATE:
11/09/2020
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Administrator Rachel DavidTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff did not provide resident with medication as prescribed.
Staff mishandling resident's medication.
INVESTIGATION FINDINGS:
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On 11/9/20 at 1135 AM, Licensing Program Analyst (LPA) Jaclyn Avila, contacted the facility via telephone and spoke with Administrator Rachel David. The purpose of the call was to deliver complaint findings via telephone due to COVID-19 and pre-cautionary measures. On February 27th, 2020 this department, California Department of Social Services-Community Care Licensing (CCL), received a complaint alleging Staff did not provide resident with medication as prescribed and Staff mishandled resident's medication. This department has investigated the complaint and the findings are as follows:

This department reviewed two Windchime Medication Incident Reports authored by a Med Tech. One report is dated 2/19/20 and provides statement that no doses have been given from the cycle medications (aspirin 81 MG) between 2/14/20 and 2/19/20 for Resident (R1). This report was authored on 2/19/20 and provided to CCL on 3/10/20. On page 2 of this report there is no investigation recorded in the portion of the report intended by Health Services Director or Executive Director. On 3/10/20, this department conducted an audit of this medications in the med room with the med tech on duty. That audit revealed that there are 5 extra pills in the bubble pack. The MAR was reviewed which did not account for the missed doses of the medication.
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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
Control Number 25-AS-20200227171701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
VISIT DATE: 11/09/2020
NARRATIVE
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The other report dated 2/21/20 details that 2/14/20, 2/15/20, 2/16/20 and 2/17/20, resident (R2) was not given Senna 8.6 mg tab. This report was given to CCL on 3/10/20 and on page 2 of this report there is no investigation recorded in the portion of the report intended by Health Services Director or Executive Director.

Director of Health and Wellness (DHW) Doug Kelly as well as Administrator Ricky David stated a staff member (S1) was released due to making medications errors. S1 admitted to this department that she provided Resident (R3) with incorrect medication.

During the course of interviews with staff, this department learned it wasn’t the practice of all med techs to document medications that weren’t given to residents on the MAR.

Based on evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be substantiated. California code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided and exit interview conducted.

An exit interview was conducted with Rachel David, Administrator via telephone and a copy of this report will be provided to the facility via email. Two copies will be sent to the facility, 1 is to be signed and returned to CCL and the other copy is to be retained by the facility.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 25-AS-20200227171701
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2020
Section Cited
CCR
87465(a)(5)
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87465(a)(5)- Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed.
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Licensee has conducted and will conduct an additional inservice training no later than 11/10/20. Licensee will submit a copy of training and roster to CCL by COB on 11/10/20
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This requirement is not met as evidenced by: Based on LPAs record review and interview, the licensee failed to provide 3 of 3 residents with medication as prescibed.

This poses an immediate Health, and Safety risk to residents in care.
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Civil penalty assessed in the amount of $250 for repeat violation (04/16/2020)
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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: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3