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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803710
Report Date: 08/11/2022
Date Signed: 08/11/2022 10:34:43 AM


Document Has Been Signed on 08/11/2022 10:34 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:PARAMOUNT HOUSE SENIOR LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:REMIGIO, RICHARDFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 81DATE:
08/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Richard Remigio - Executive DirectorTIME COMPLETED:
10:34 AM
NARRATIVE
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Licensing Program Analyst (LPA) Fernandes-Goes arrived unannounced with the purpose of closing a complaint investigation. During subsequent #21-AS-20220603141110 complaint investigation, Department learned that there are related deficiencies observed during the visits. LPA met with xxxxx. Following items were observed during investigation visits:

LPA observed during resident’s R1 file review and interviews on 6/10, 6/13, 7/7, 7/11, and 8/3/2022, Department learned that facility had a report suspected abuse for resident R1. Facility learned of incident on June 2, 2022 as per administrator Richard Remigio and other staff; at the time of the visit facility had not conducted any investigation. Facility failed to report suspected abuse and/or able to provide investigation documentation. Suspected abuse in addition to incident report that occurred on June 2, 2022 were not submitted to the Department until after complaint visit to the facility conducted on June 13, 2022. (see copy of documentation, LIC 809-D)

In addition, Department on 6/13/22 requested documentation on training for staff S1 & S2 and again on 7/11 and 8/3/2022 LPA emailed and visited facility requesting additional information on training records. Administrator stated that request had been submitted to Jessica Garcia RCD (Resident Care Director); no extra documentation was received until copy of training records were provided on 8/3/2022. Department observed that staff S1 and S2 don’t have all required training as required on Health & Safety Code (H&S). Staff S2 total training hours of 30.25 with 8.15 hrs. being on medication training; training dates are between 10/04/21 and 18/4/22. S1 was hired as caregiver and medication technician on 9/03/21; there is no proof of medication shadowing training with only 8.15 hrs in medication training. Staff S2 was hired as caregiver on 8/30/21; total training hours not identified on training documentation; only 5 trainings on file – Abuse and Neglect, Infection Control, Empathy & Hoyer lift, Elder Abuse & Hydration, and COVID-19 between 12/29/21 and 6/29/22. Department observed that staff S1 and S2 don’t have all training needed as required on Health & Safety Code (H&S). (see copy of documentation, LIC 809-D)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
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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Document Has Been Signed on 08/11/2022 10:34 AM - 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING

FACILITY NUMBER: 486803710

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 08/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2022
Section Cited

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87211 Reporting Requirements- A written report shall be submitted... -This requirement is not met as evidenced by: *Based on interview, file review, & suspected abuse report facility didn't comply w/this
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section for 1 of 1 resident which posses potential health, safety, personal rights risk to residents in care. CCL has learned of R1 incident which was reported to CCL and only reported by facility after CCL's visit. (see copies)
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and a plan on how facility will ensure that this requirement will be followed to CCL by POC date of 8/25/2022 in order to clear this citation.
Type B
08/25/2022
Section Cited

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§1569.625 Staff training: legislative findings…This requirement is not met as evidenced by:Based on record review & interviews,the licensee did not comply w/the section cited above in 2 out of 2
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caregiver staff which poses a potential health & safety risk to persons in care. Department learned during staff training review that S1 & S2 have no proof 40 hrs of initial training and/or medication shadowing on file.
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including agency staff have all required training on file to be reviewed by the Department and plan on how facility will track training by POC date of 8/25/2022 in order to clear this citation. (CP)
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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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