486803710-8-11-2022-21-AS-BMOS-CHKNCQ-20220823102108

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 08/11/2022
Date Signed: 08/11/2022 10:32:14 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/03/2022 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220603141110

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	REMIGIO, RICHARD		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS: 81	DATE:	08/11/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Richard Remigio - Executive Director		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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Personal Rights

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes arrived unannounced for the purpose of closing the investigation and met with Richard Remigio - Executive Director.

On June 13, 2022, LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During tour of the facility with staff & documentation review on June 13, 2022; and interviews with complainant, residents, and staff on 6/10, 6/13, 7/7, and 7/11/2022, 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 was not submitted to the (continued 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220603141110

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/11/2022

NARRATIVE

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Department until after complaint visit to the facility conducted on June 13, 2022. (see Case Management dated 8/11/2022) Resident R1’s physician report states that resident has MCI. R1 was interviewed and wasn’t able to recall any occurrence of June 1/June 2. LPA made multiple attempts to interview alleged abuser with no success and there was no witness to this event. Department obtained a Declaration Statement from staff which only states that resident R1 “couldn’t ‘be’ change because” was “grabbing hands”. There is a record on R1’s file from hospice in which nurse states that found “left skin tear plus bruising noted to hand/arm” and that resident R1 stated that “caregiver was angry and pulling on arm”. Staff interviewed stated that “PM shift states that R1 can be very irritable; R1 has a very soft skin. There were 4 residents interviewed who had no complaints of staff. Based on interviews, Declaration Statement, and Vacaville Police Report, Department wasn’t able to prove or disprove that resident had personal rights violated by facility staff at this time.

A finding that the complaint allegation of "Personal Rights.” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

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