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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 02/17/2021
Date Signed: 02/17/2021 06:03:23 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2020 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20200429113836
FACILITY NAME:PARAMOUNT HOUSE SENIOR LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:SIOBHAN LEHMANFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 75DATE:
02/17/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kathleen Berito, Resident Service DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff has access to discontinued medication drum.
Staff are not submitting incident reports in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tobola conducted a complaint investigation regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with Resident Service Director, Kathleen Berito by tele-visit. Facility was toured, records were reviewed and interviews with staff were conducted.

Complaint alleges that staff has access to discontinued medication drum. Based on review of the facility program plan medical technicians are responsible for disposing medications in a medical waste receptacle. In addition, based on a facility tour, observations and photo evidence LPA observed multiple containers and boxes of resident medications requiring destruction unsecured on a medication room shelf outside of the medication locked cabinets and accessible to staff that are not trained to handle medications.

Continued onto LIC9099-C.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
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 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2020 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20200429113836

FACILITY NAME:PARAMOUNT HOUSE SENIOR LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:SIOBHAN LEHMANFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 75DATE:
02/17/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kathleen Berito, Resident Service DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Questionable death
Staff person was observed handling destroyed medications
Staff person is rough with residents
Staff person makes inappropriate comments to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tobola conducted a complaint investigation regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with Resident Service Director Kathleen Berito by tele-visit. Facility was toured, records were reviewed and interviews with staff and residents were conducted.

Complaint alleges the facility is responsible for a questionable death of resident R1. Based on review of records it was found that resident R1's cause of death was from poorly controlled diabetes type 2. R1's Needs & Service Plan and Physician's Report indicated that R1 was independent and able to administer R1's own medications. R1's Medication Records indicted that R1 was administered the correct prescribed medications.

Complaint alleges staff person was observed handling destroyed medication. Based on multiple staff interviews LPA received conflicting information related to the allegation, therefore the allegation is found to be unsubstantiated.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20200429113836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING
FACILITY NUMBER: 486803710
VISIT DATE: 02/17/2021
NARRATIVE
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Complaint alleges that staff person is rough with residents and staff person makes inappropriate comments to residents. Based on multiple staff and resident interviews LPA received contradicting information related to the allegation, therefore the allegation is unsubstantiated.

A finding that the complaint allegations of a questionable death, staff person observed handling destroyed medications, staff person is rough with residents and staff person makes inappropriate comments to residents are UNSUBSTANTIATED meaning that although the allegations may have happened, there is not a preponderance of evidence to prove that the allegations occurred.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2020 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20200429113836

FACILITY NAME:PARAMOUNT HOUSE SENIOR LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:SIOBHAN LEHMANFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 75DATE:
02/17/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Kathleen Berito, Resident Service DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff person is not qualified
Management does not have a copy of the resident's file.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tobola conducted a complaint investigation regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with Resident Service Director Kathleen Berito by tele-visit. Facility was toured, records were reviewed and interviews with staff and residents were conducted.

Complaint alleges that staff person is not qualified. Based on interviews with residents and review of staff training records it was found that staff S1 has the required medication training completed and on file along with several years of caregiver and medtech experience.

Complaint alleges that facility does not have copy of resident's (R1) file. Based on record review LPA determined that the facility keeps copies of former resident documents up to 5 years. LPA received and reviewed R1's resident files and confirmed that the facility still has the documents recorded.

This agency has investigated the above allegations. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without a reasonable basis.
***Amended copy of original report** Signatures on file
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20200429113836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING
FACILITY NUMBER: 486803710
VISIT DATE: 02/17/2021
NARRATIVE
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Compliant alleges that staff are not submitting incident reports in a timely manner. Based on review of incident reports submitted by the facility it was determined that the facility had failed to submit several incident reports within the required 7 days of occurrence between the reviewed dates of March 2020 to June 2020.

The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.

Signatures on file.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20200429113836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING
FACILITY NUMBER: 486803710
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/01/2021
Section Cited
CCR
87208(a)
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87208(a)Plan of Operation-Each facility shall have and maintain a current, written definitive plan of operation. This requirement is not met as evidenced by:

Based on observation, interviews & record review LPA learned that the facility failed to follow the facility plan of operation**
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Administrator failed to follow the facility plan of operation regarding the handling of medication requiring disposal. Administrator agrees to update the plan of operation regarding medication destruction to ensure medications requiring destruction are properly disposed of and are only accessible to staff trained to handle medications.
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**regarding the handling of medication upon expiration, discontinuance and discharge or death of a resident. LPA observed multiple medications requiring destruction improperly stored on an unsecured shelf in the medication room. This poses a potential health & safety risk to residents in care.
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Administrator to submit the updated plan of operation to CCL by POC due date 3/1/2021.
Type B
03/01/2021
Section Cited
CCR
87211(a)(1)
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87211(a)(1) Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence. This requirement was not met as evidence by:

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Administrator failed to ensure incident reports are submitted to CCL based on Title 22 regulations. Administrator agrees to submit written self certification that they have read and understand Regulation 87211 as well as a plan of how the facility will follow the regulation requirements by POC due date 3/1/2021.
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Based on record review LPA learned that the facility failed to submit 11 separate incident reports within the required 7 days of occurrence between the dates of March 2020 to June 2020. 5 of the 11 incident reports were submitted over 10 days of occurrence. This poses a potential health & 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: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6