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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 12/19/2024
Date Signed: 12/19/2024 10:33:55 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
11/13/2024 and conducted by Evaluator Julie Florio
COMPLAINT CONTROL NUMBER: 21-AS-20241113104034
FACILITY NAME:PARAMOUNT HOUSE SENIOR LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:SAMANIEGO,AGUSTINFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 70DATE:
12/19/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Agustin Samaniego, Executive DirectorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff yells at residents.
Staff do not ensure resident's incontinence needs are being met.
INVESTIGATION FINDINGS:
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On 12/19/2024, Licensing Program Analysts (LPAs) Julie Florio and Robert Frank arrived unannounced to deliver complaint investigation findings regarding the above allegations and met with Agustin Samaniego, Executive Director (ED). Reporting Party (RP) alleges that Staff 1 (S1) yells at residents and that Staff do not ensure Resident 1’s (R1’s) incontinence needs are being met, because staff are not responding timely to calls for help and are not cleaning R1 when changing their incontinent care briefs. Further, RP states that R1 is prone to urinary tract infections (UTIs) resulting in recent hospitalizations.

LPA Julie Florio conducted 10-day complaint investigation visit on 11/14/2024 and obtained documents, made observations, and conducted interviews with Staff 2 (S2) and ED. LPA conducted a subsequent complaint investigation visit on 12/06/2024 and obtained documents, made observations, and conducted interviews with S2, ED, and R1.

Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
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 2
Control Number 21-AS-20241113104034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING
FACILITY NUMBER: 486803710
VISIT DATE: 12/19/2024
NARRATIVE
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Continued from LIC9099...

Based on LPA's interviews, LPA received conflicting information regarding the above allegations including R1 confirming that they had never been yelled at by S1, who has worked at the facility for more than three years with no prior complaints for this issue. LPA obtained copies of R1’s Physician’s Report, Assessment, Resident Appraisal, bathing records, incontinent care records, Needs and Services Care Plan, call logs from 10/1/2024 through 11/14/2024, and R1’s hospital discharge records from 10/29/2024-11/7/2024; 11/14/2024-11/15/2024; and 12/1/2024-12/03/2024, which confirm that R1 has a known, documented history of UTIs as the result of kidney stones and is currently working with their physicians to address this recurrent issue. Additionally, LPA confirmed that requests for assistance, including assistance with incontinent care, over the last month were addressed within an average response time of 13 minutes, and LPA observed documented bathing and peri-care refusals at least 4 times between 10/4/2024 and 12/1/2024.

Based on record review, interviews conducted, and observations made, the allegations of Staff yells at residents and Staff do not ensure resident's incontinence needs are being met are UNSUBSTANTIATED. A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to ED. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2