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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 045001959
Report Date: 12/16/2024
Date Signed: 12/16/2024 12:43:11 PM

Document Has Been Signed on 12/16/2024 12:43 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/
DIRECTOR:		MORRIS, MARKFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY: 120TOTAL ENROLLED CHILDREN: 0CENSUS: 47DATE:
12/16/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator, Mark MorrisTIME VISIT/
INSPECTION COMPLETED:
11:00 PM
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On December 16, 2024 at approximately 10:00 AM, Licensing Program Analyst (LPA) Farhaan Sarangi arrived at Windchime of Chico unannounced to conduct a Case Management-Legal/Non-Compliance inspection 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, Mark Morris and was granted access into the facility.

During today's inspection, LPA toured the facility with the Administrator. 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.

(Report continued on LIC 809C)
Lauren CrockerTELEPHONE: (916) 202-0832
Farhaan SarangiTELEPHONE: (916) 307-0474
DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2024
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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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
VISIT DATE: 12/16/2024
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4. Facility shall ensure that the administration of medications to residents are in full compliance with regulation section 87465 at all times.
- LPA observed that 1 out of 5 residents did not have medication orders retained in the resident file. LPA observed the resident files during a Required 1 year inspection conducted on December 16, 2024. The deficiency will be cited on the Required 1 year inspection dated for December 16, 2024.

5. Staff shall have criminal background clearance
- LPA checked criminal background clearance for all staff who were present at the facility.

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 not be in compliance at this time. Exit interview conducted and copy of this report was signed and given to the Administrator.

SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 202-0832
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: (916) 307-0474
LICENSING EVALUATOR SIGNATURE:

DATE: 12/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024
LIC809 (FAS) - (06/04)
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