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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 12:42:59 PM

Document Has Been Signed on 12/16/2024 12:42 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:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator, Mark MorrisTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On December 16, 2024 at approximately 11:00 AM, Licensing Program Analyst (LPA) Farhaan Sarangi arrived unannounced at Windchime of Chico to conduct a Required 1 year inspection LPA met with the Administrator, Mark Morris and was granted access into the facility. Business Officer Manager, Jennifer Cuffington was also present during the inspection.

LPA and Administrator toured the facility. LPA observed the facility to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on October 2024 at the time of the inspection. All smoke detectors sound directly to the fire station. Water temperature in facility bathroom measured at 108 degrees, within acceptable range of 105 to 120 degrees F. LPA observed sufficient perishable and non-perishable foods located in the kitchen. There are special provisions made for individuals with special dietary needs. Food menu was presently available for viewing during the inspection. Medications were centrally stored and locked. Cleaning products and other toxins are located in the laundry room that was locked and inaccessible to residents in care. There was a supply of linens, cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents in the common areas at the facility were supplied with individual paper towels and hand soap. Bathrooms in resident’s rooms have a towel and soap. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present. A tour of vacant and unoccupied room was conducted and found to be in compliance. LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms of COVID-19 or other infectious diseases are present in the facility. LPA reviewed the Infection Control Plan and found that to be appropriate during the inspection. First Aid kit was inspected and found to be appropriate during the inspection. Emergency Disaster Plan was reviewed and found to be appropriate. Emergency Disaster Drill was last conducted in November 2024. (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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LPA reviewed 5 of 5 resident files. However, during the medication review, LPA and Administrator observed that the medication list for 1 out of 5 residents was not retained (See-LIC809D). LPA educated the Administrator on the importance of ensuring that all medications are afforded to the residents and dispensed as outlined in Physicians Orders. LPA reviewed staff files and found those files to be appropriate during the inspection. LPA requested the following documents to be sent:

LIC 500- Personnel Report
LIC 308- Designation of Facility Responsibility
LIC 309- Administrative Organization
Most up-to-date Liability insurance
Control of Property
Register of residents
Most recent Fire Inspection Report

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator along with Appeal Rights.
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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Document Has Been Signed on 12/16/2024 12:42 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
87465(c)(1) Incidental Medical and Dental Care:

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

(1) There is written direction from a physician, on a prescription blank, specifying the name of the resident, the name of the medication, all of the information in Section 87465(e), instructions regarding a time or circumstance (if any) when it should be discontinued, and an indication when the physician should be contacted for a medication reevaluation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 5 resident files did not have Medication Orders retained in the file which poses an potential health, safety, or personal rights risk to persons in care.
POC Due Date: 12/17/2024
Plan of Correction
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Plan of Correction shall include the Licensee/Administrator to fill out an LIC-9098 understanding of the regulation. Furthermore, Licensee/Administrator shall review ALL resident files to ensure that Medication Orders are retained in the resident files. Licensee/Administrator shall conduct staff training on ALL staff who dispense medications to residents in care. LPA requested a statement on a plan for future compliance and ensuring that the regulation will be followed.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lauren CrockerTELEPHONE: (916) 202-0832
Farhaan SarangiTELEPHONE: (916) 307-0474

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

LIC809 (FAS) - (06/04)
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