486803710-2-19-2021-21-AS-KMOA-BYYM2Y-20210310081415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 02/18/2021
Date Signed: 02/19/2021 10:53:08 AM

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
06/05/2020 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20200605144000

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	SIOBHAN LEHMAN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS: 75	DATE:	02/18/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Kathleen Brito, Resident Service Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff mismanaging residents’ medications.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Tobola conducted a complaint investigation regarding the above allegation. Due to COVID-19 restrictions LPA Tobola met with Resident Service Director, Kathleen Brito by tele-visit. Facility was toured, records were reviewed and interviews with multiple staff, residents and outside parties were conducted.

Complaint alleges staff are mismanaging residents' medications. Based on observations, a tour of the facility, interviews with staff and document review LPA found that staff S1 was responsible for a missing narcotic medication for resident R1 during a medciation audit conducted on 1/25/2021. Additionally LPA was informed by Resident Service Director and LVN of two additional medication errors from auditing medication counts several months back for staff S2 and former staff S3. However, the facility does not have documentation of corrective actions.

Continued onto LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

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 5

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
06/05/2020 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20200605144000

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	SIOBHAN LEHMAN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS: 75	DATE:	02/18/2021
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Kathleen Brito, Resident Service Director		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident are being provided another residents medication.
Staff speak inappropriate to residents.
Staff hit residents.
Residents are not being changed in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 Brito by tele-visit. Facility was toured, records were reviewed and interviews with multiple staff, residents and outside parties were conducted.

Complaint alleges residents are being provided medications belonging to another resident. Based a sample medication record review, interviews with staff and residents LPA received conflicting information related to the allegation, therefore the allegation is found to be unsubstantiated.

Complaint alleges staff speak inappropriate to residents and staff hit residents. Based on review of resident documents, observations and a tour of the facility LPA did not find any corroborating evidence related to the allegations. In interviews with multiple staff and residents LPA received conflicting information related to the allegations, therefore the allegations are found to be unsubstantiated.

Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

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 5

Control Number 21-AS-20200605144000

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: 02/18/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Complaint alleges residents are not being changed in a timely manner. LPA reviewed bathing schedules and bathing daily chart notes between January 2021 and February 2021 and did not find any corroborating evidence regarding the allegation. LPA found that staff change residents with continence care every 3 hours. However, based on a facility tour and interviews with staff and residents LPA received conflicting information, therefore the allegation is found to be unsubstantiated.

A finding that the complaint allegations of residents are being provided another residents medication, staff speak inappropriate to residents, staff hit residents and residents are not being changed in a timely manner are UNSUBSTANTIATED meaning that although the allegations may have happened, there is not a preponderance of evidence to prove that the allegation occurred.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20200605144000

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: 02/18/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/02/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	Amended 87465(a)(5) Incidental Medical and Dental Care Services. The licensee shall assist residents with self-administered medications when needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator failed to ensure proper management of medication administration. Administrator agrees to update the medication audit plan to ensure resident medication are kept safe. Administrator to submit the updated plan to CCL by POC due date 3/2/2021.
	8 9 10 11 12 13 14	Based on interviews with staff and staff record review it was found that staff S1 was responsible for a missing narcotic medication for resident R1 from a medication audit conducted on 1/25/2021. This poses a potential health & safety risk to clients in care.	8 9 10 11 12 13 14
	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: Kimberley Mota	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20200605144000

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: 02/18/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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 DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5