045001959-3-11-2025-59-AS-LCRR-DEVL9R-20250318083355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 03/11/2025
Date Signed: 03/11/2025 10:41:44 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
03/06/2025 and conducted by Evaluator Kayla Adkison

COMPLAINT CONTROL NUMBER: 59-AS-20250306100946

FACILITY NAME:	WINDCHIME OF CHICO		FACILITY NUMBER:	045001959
ADMINISTRATOR:	MORRIS, MARK		FACILITY TYPE:	740
ADDRESS:	855 BRUCE RD		TELEPHONE:	(530) 566-1800
CITY:	CHICO	STATE: CA	ZIP CODE:	95928
CAPACITY:	120	CENSUS: 45	DATE:	03/11/2025
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Mark Morris, Executive DIrector		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are sleeping during working hours

INVESTIGATION FINDINGS:

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03/11/2025 09:30 AM Licensing Program Analysts (LPAs) Kayla Adkison and Rebecca Knight made an unannounced visit to the facility and met with Executive Director (ED) Mark Morris. The purpose of this visit was to open a complaint investigation.

LPAs interviewed the ED and Resident Care Coordinator(RCC) during the visit. LPas toured the facility during the visit.

Cont. on Lic 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 475-5882
LICENSING EVALUATOR NAME: Kayla Adkison	TELEPHONE: 916-208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250306100946

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: 03/11/2025

NARRATIVE

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Staff are sleeping during working hours- SUBSTANTIATED

It was alleged that staff are sleeping during working hours.

LPAs reviewed photographs that were submitted with the complaint. One photograph showed an individual laying on a couch sleeping. Another photograph showed another individual sitting in a chair with their feet up covered in a blanket. Both individuals are wearing scrubs. The photographs were taken in different rooms.

During the visit LPAs toured the facility and observed a chair in the memory care unit in which one staff was sleeping in the photograph. LPAs observed a couch located in the library of the assisted living unit in which a separate staff was sleeping.

ED and RCC reviewed the photographs and confirmed the identity of the staff pictured. Also confirmed both staff are currently employed at the facility. ED stated staff are allowed to sleep during there scheduled break, however, they are provided a break room where this should take place.

It was determined that facility staff were sleeping in the common areas of the facility during the NOC shift. This allegation is substantiated.

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. Appeal rights were provided. Exit interview was conducted and the report was provided to Executive Director Mark Morris..

SUPERVISOR'S NAME: Lauren Crocker	TELEPHONE: (916) 475-5882
LICENSING EVALUATOR NAME: Kayla Adkison	TELEPHONE: 916-208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

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Control Number 59-AS-20250306100946

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: 03/11/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/25/2025 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by	1 2 3 4 5 6 7	ED agrees to conduct staff training on the requirement for staff to remain awake and alert during all shift to ensure the health & safety of residents in care.
	8 9 10 11 12 13 14	Based on document review and interviews the licensee did not ensure that staff remained awake and alert during NOC shift. This poses a potential Health, Safety and Personal Rights risk to residents in care.	8 9 10 11 12 13 14	ED shall submit signed and dated staff training attended sheet to LPA as proof of correction.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Crocker	TELEPHONE: (916) 475-5882
LICENSING EVALUATOR NAME: Kayla Adkison	TELEPHONE: 916-208-6251
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

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