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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 06/11/2024
Date Signed: 06/11/2024 11:06:09 AM

Substantiated


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
06/03/2024 and conducted by Evaluator Jaynae Boyles
COMPLAINT CONTROL NUMBER: 59-AS-20240603085732
FACILITY NAME:WINDCHIME OF CHICOFACILITY NUMBER:
045001959
ADMINISTRATOR:PRIMEAU, JACOBFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 59DATE:
06/11/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administration- Jacob Primeau TIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff are not distributing a resident's medication as prescribed.
Staff do not ensure that residents' medications are properly stored.
INVESTIGATION FINDINGS:
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On June 11, 2024 LPA Boyles made an unannounced visit to the facility and met with Executive Director.
The purpose of this visit was to open a complaint investigation.

LPA toured the Medication rooms and met with the Medication Technition on duty to review electonic medication administration logs and Centerally Stored Medication Log.

Based on interviews and evidence obtained during the investigation, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22), is being cited on the attached LIC9099D. Civil Penaltys assessed as a result of todays visit.

Appeal rights were provided. An exit interview was conducted. A copy of the report was provided to administrator.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
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 3
Control Number 59-AS-20240603085732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/11/2024
NARRATIVE
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LPA reviewed the EMAR of the file of R1. It was indicated that R1 received 27 doses of the medication on the EMAR, but on the daily count the record indicated that the resident was given 21 doses of the medication. There is no record of this medication on the CSML. Med Tech reported that the family picked up the medication from the pharmacy and provided it to the facility. There is no initial record of receiving the medication as it is is recorded in the CSML. Med Tech reported that the facility no longer has the bottle in which the medication came to the facility.

EMAR indicated that the resident was given the medication from 6/2-6/8, However, this report indicated that the medication was missed from 6/1-6/3 because the medication was not in the facility. The EMAR indicated that 27 doses of this medication were given to the resident.

The facility placed the medication on Controlled Drug form which indicates that the facility was given the medication starting 6/3, and it ended on 6/8 at noon.

The order for this medication is that it be given four times a day for 7 days. This medication was not listed on the CSML to indicate when the medication was received, and how much medication was given to the facility.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Jaynae BoylesTELEPHONE: (916) 208-6251
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 59-AS-20240603085732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/11/2024
Section Cited
CCR
87465(h)(6)(A-F)
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(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
(A)The name of the resident for whom prescribed.
(B)The name of the prescribing physician.
(C)The drug name, strength and quantity.
(D)The date filled.
(E)The prescription number and the name of the issuing pharmacy.
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The facility will ensure that all residents have a completed CSML in their file at the facility. The facility will train the staff on how to completed these forms, and provide proof to the LPA.

CP Assessed.
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This requirement has not been met as evidenced by:
The LPA observed a medication listed on the EMAR to not be listed on the CSLM. Furthermore, the facility has inconsistant documentation of how much of the medication arrive to the facility.
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ILS
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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: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3