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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 04/08/2024
Date Signed: 04/08/2024 03:13:13 PM


Document Has Been Signed on 04/08/2024 03:13 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:FENNEL, LISAFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 54DATE:
04/08/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator- Lisa Fennel TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Jaynae Boyles arrived at the facility unannounced on 4/8/2024 to conduct a Case Management Legal visit in accordance with the Stipulation and Order effective 3/23/2021. A copy of the Stipulation and Order is posted in a conspicuous place and is available for review upon request. LPA met with the Administrator, Lisa Fennel and by phone, Carly Taylor (CCO)and Simone Turner (Regional Operations Support).

During today's visit, LPA reviewed the following stipulations of the order:

1. Staff shall be sufficient in number
-During inspection, LPA observed LIC 500s and staff schedule and found staff to be sufficient in number. The facility is in compliance with the stipulation staffing ratios of Memory care 1:6 and Assisted Living 1:10.

2. Administrator shall prepare monthly rosters of all staff to the LPA
- Administrator will continue to email the roster monthly.

3. Facility shall report unusual incidents
- Facility will ensure that all unusual incidents are reported to the Department. The facility received a citation on todays date for noncompliance. Administrator will review and send the Unusual Incident reporting policy and procedure to the LPA.

4. Facility shall ensure that the administration of medications to residents are in full compliance with regulation section 87465 at all times.
- LPA observed incident reports of medication errors within the last three months. LPA substantiated a complaint regarding medication administration errors within the last three months.

5. Staff shall have criminal background clearance
- LPA checked criminal background clearance for all staff

6. Facility stall notify all present and future residents of the stipulation.
- LPA observed a crafted letter used in the admissions agreement to notify new residents of the stipulation.

LPA observed facility to be in compliance and residents receiving care. No deficiencies are being cited. Exit interview conducted and copy of report provided.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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