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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 045001959
Report Date: 11/09/2020
Date Signed: 11/12/2020 10:48:50 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/11/2020 and conducted by Evaluator Jaclyn Avila
COMPLAINT CONTROL NUMBER: 25-AS-20200211160806
FACILITY NAME:WINDCHIME OF CHICOFACILITY NUMBER:
045001959
ADMINISTRATOR:DAVID JR, RICKYFACILITY TYPE:
740
ADDRESS:855 BRUCE RDTELEPHONE:
(530) 566-1800
CITY:CHICOSTATE: CAZIP CODE:
95928
CAPACITY:120CENSUS: 57DATE:
11/09/2020
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Rachel DavidTIME COMPLETED:
12:10 PM
ALLEGATION(S):
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On going theft of resident's property
Facility not reporting theft of resident's property
INVESTIGATION FINDINGS:
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On 11/9/2020 at 11 AM, Licensing Program Analyst (LPA) Jaclyn Avila, contacted the facility via telephone to deliver complaint findings via telephone due to COVID-19 and pre-cautionary measures and spoke with administrator Rachel David.

On February 11th, 2020 this department, California Department of Social Services-Community Care Licensing (CCL), received a complaint stating Windchime does not have an adequate theft and loss program. The complainant alleged there is ongoing theft of resident's property and the facility is not reporting theft of resident's property.

This department has conducted an investigation to include review of documents and interviews with the resident, family of the resident and Windchime of Chico’s administrative staff. The findings are as follows:

Continued on LIC 9099-C
Substantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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 5
Control Number 25-AS-20200211160806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
VISIT DATE: 11/09/2020
NARRATIVE
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This department conducted an interview with Administrator Ricky David who stated, “Its recently come up that not all residents have completed the required theft and loss forms.” Resident’s (R1) file did not contain the clients/resident personal property and valuables form (LIC 621) in violation of 87506(b)(16) CCR Title 22. R1’s was admitted to the facility July 2019 and discovery of the LIC 621 was not in her resident file occurred February 2020. Administrator said since the discovery, R1 has been provided with the LIC 621. On 2/18/20, Administrator acknowledged R1 reported the theft/loss of silver spoons, candy bars and binocular glasses. When asked what the facility does with reports of theft and loss, Administrator stated, “residents are assisted in looking for their items and 9/10 times the item is located.”

This department conducted interviews with Windchime administrative staff and found several items were reported stolen and/or missing by R1 to include: Silver spoons, opera binocular glasses, costume jewelry, medication, earrings and a camera from October 2019 to February 2020. Windchime did not provide documentation as required by Health and Safety code 1569.153(c) for all items with a value of $25 or more within 72 hours. This department was not provided with documentation as required for the opera binocular glass, medication, and camera. Director of Health and Wellness (DSW) Doug Kelly said this was reported to him by R1 in October 2019. DSW recorded the report of lost/stolen medication (Norco) in R1’s chart notes. Administrative staff admitted documentation was not done when the resident initially made reports of items lost and/or stolen and “it wasn’t until later it would be deemed necessary.” The first Windchime Missing Item report form that was completed and provided to CCL was dated 2/14/20 at the time of site visit. CCL has only received one incident report (LIC 624) regarding the theft. This incident report is dated 3/10/20 and was for a “necklace” and “a figurine.” Windchime Business of Management stated Windchime provided R1 with a credit of $350 for items alleged to be missing.

Windchime administrative staff acknowledged Law Enforcement was called to assist R1 regarding R1’s theft complaint 1/21/20, however, Windchime did not conduct their own investigation in compliance of 1569.153 H&S nor was an incident report (LIC 624) completed. DSW said he would obtain copies of R1’s reports to the Chico Police Department. At the time of these findings Windchime has not provided CCL with these reports.

CCL obtained copies of theft reports made by R1 to law enforcement (Chico Police Department) dated 1/6/20 and 1/21/20.

Continued on LIC 9099-C
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 25-AS-20200211160806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926
FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
VISIT DATE: 11/09/2020
NARRATIVE
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Windchime failed to acquire an inventory sheet upon R1’s admission. Windchime failed to properly document items reported loss/stolen from October 14, 2019-February 12, 2020. Windchime did not conduct nor document investigations for that time period or implement measures to prevent continued theft from R1. Its wasn’t until after law enforcement, family and ombudsman involvement that R1’s reports of theft, were being documented by the facility.

Based on evidence obtained, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be substantiated. California code of Regulations, (Title 22), is being cited on the attached LIC 9099D. Appeal rights were provided and exit interview conducted.

An exit interview was conducted with Rachel David, Administrator via telephone and a copy of this report will be provided to the facility via email. Two copies will be sent to the facility, 1 is to be signed and returned to CCL and the other copy is to be retained by the facility.
SUPERVISOR'S NAME: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 25-AS-20200211160806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/10/2020
Section Cited
CCR
87468.2(25)
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87468.2(25)-Personal Rights- To protection of their property from theft or loss according to Health and Safety Code sections 1569.152, 1569.153, and 1569.154.
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Licensee agrees to put a theft and loss book in place. Licensee will conduct an inservice training on policy and regulations related to theft and loss on 11/09/20. Licensee will provide CCL with the updated policy, training and roster by COB on 11/10/20.
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This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to protect 1 of 1 residents property from theft or loss.

This poses an immediate Health, and Safety risk to residents in care.
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Type A
11/10/2020
Section Cited
HSC
1569.269
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1569.269(a)(10)- Enumerated rights; severability-Residents of residential care facilities for the elderly shall have all of the following rights: To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.This requirement is not met as evidenced by:
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License agrees to conduct an inservice training on resident rights. Licensee will provide CCL a copy of training and a roster by COB on 11/10/20
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Based on record review and interview, the licensee failed to protect 1 of 1 residents from theft of medication, cash, personal belongings. Licensee failed to conduct an investigation in an attempt to identify a suspect. Licensee did not contact police or write a SOC 341.This poses an immediate Health, and Safety risk to residents in care.
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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: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 25-AS-20200211160806
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 520 COHASETT RD., STE. 170
CHICO, CA 95926

FACILITY NAME: WINDCHIME OF CHICO
FACILITY NUMBER: 045001959
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2020
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) reporting requirements-A written report shall be submitted to the licensing agency and to the person responsible for the resident in seven days..specified in (D).This report shall include the resident's name..date and nature of event;...findings, treatment and disposition of case. Any incident which threatens the welfare, safety or health
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Licensee agrees to conduct inservice training on reporting requirements to include mandated reporting. Licensee will send a copy of training and a staff roster of those in attendance by COB on 11/10/20
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of a resident, such as psychological abuse of a resident by staff...This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to provide written reports to licensing for 1 of 1 residents on going reports of theft or loss.
This poses a potential Health, and Safety risk to residents in care.
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Type B
11/24/2020
Section Cited
CCR
87506
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87506 b(16)- Resident Records-Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.This requirement is not met as evidenced by: Based on record review and interview, the licensee failed to:
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Licensee agrees to audit all resident files to ensure all residents have required records. Licensee agrees to notify CCL no later than 11/24/20 that task has been completed
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Obtain records of residents cash resources as specified in section 87217 for 1 of 1 residents
This poses a potential Health, and Safety risk to residents in care.
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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: Rayna L BrysonTELEPHONE: (530) 895-5033
LICENSING EVALUATOR NAME: Jaclyn AvilaTELEPHONE: (530) 895-4275
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5