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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 04/08/2024
Date Signed: 04/08/2024 01:29:05 PM

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
02/23/2024 and conducted by Evaluator Jaynae Boyles
COMPLAINT CONTROL NUMBER: 59-AS-20240223162448
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
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Lisa Fennel TIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Failure to report unusual incident reports.
INVESTIGATION FINDINGS:
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04/08/2024 Licensing Program Analyst (LPA) Jaynae Boyles made an unannounced visit to the facility and met with Executive Director. The purpose of this visit is to deliver the results of a complaint investigation.


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. Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies during the visit are documented on the 9099-D.

Exit interview conducted with Executive Director and a copy of the report along with appeal rights were provided.

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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 59-AS-20240223162448
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: 04/08/2024
NARRATIVE
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During the investigation process the LPA reviewed the electronic file for review of incident reports submitted to the Department and interviewed six current employees and one former employee.

LPA investigated the allegation, “Failure to report unusual incident reports”. Of the six staff that were interviewed five indicated that a resident (R1) was able to leave the facility through a locked door using a key that R1 found in the memory care facility. It was reported that R1 was able to leave the facility two times in one day and one more occasion the following day.

LPA reviewed the electronic file for the facilities submitted incident reports and did not receive an incident report for R1 regarding the elopement that occurred in February 2024.

The facility did not report the two incidents to the Department within the required time frame. The Department was notified of the two incidents that occurred in February 2024.
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 59-AS-20240223162448
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: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/08/2024
Section Cited
CCR
87211(a)(D)
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87211(a)(D) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to…Any incident which threatens the welfare, safety or health of any resident or unexplained absence of any resident. This requirement is not met as evidence by:
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Licensee had a training with all staff that was held by the local Ombudsman and to review the eloping procedures and how to report all incidents in the facility and send them to the Department.
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Based on interviews and record review, the licensee did not submit incident reports to the Department regarding a resident’s unexplained absence at the facility when resident left the facility alone and unassisted in two separate incidents.
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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: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3