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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 05/15/2025
Date Signed: 05/15/2025 12:36:41 PM

Substantiated


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
02/13/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250213151746
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: 79DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Agustin Samaniego, AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Personal Rights, facility is not answering phone line
INVESTIGATION FINDINGS:
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On 5/15/2025, Licnesing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above alligation and met with Agustin Samaniego, Administrator.

Personal Rights, facility is not answering phone line- Complainant alleges resident has to make several, described as four to five attempts, calls prior to receiving a response from staff. Additionally, when resident calls are not answered are sent to the answering machine. Further review of investigation revealed response time is also refering to call bells. During the investigation LPA called facility line over 5 times lastly 5/14/2025 at 4:18pm and was answered on the first ring and was answered every time prior. LPA conducted interviews with residents and staff. Interviews with Administrator and RSD indicated staff should respond to a residents call within 15 minutes. Documents obtained confirmed that over a 1-month period (1/5/25 -2/20/25), R1 waited 15 minutes or more 57 times before receiving staff assistance, 7 of which were for wait times greater than 30 minutes.
Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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 4
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
02/13/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250213151746

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: DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Agustin Samaniego, AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident incontinent care needs not met
Facility did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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3
4
5
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9
10
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13
On 5/15/2025, Licnesing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above alligations and met with Agustin Samaniego, Administrator.

Resident incontinent care needs not met- Reporting Party alleges, due to staff not cleaning resident properly is related to resident's repeated urinary tract infections. LPA conducted facility visits on 2/20/2025, 5/1/2025, and 5/15/2025, conducted interviews with staff, residents, and outside parties, made observations, and obtained documents. Interview with resident (R1) and hospital discharge records from 2/9/2025-.2/14/2025 (implanted stent & removal of kidney stones);5/10/2025;and 5/13/2025, which confirm that R1 has a known, documentd history of UTIs as the reult of kidney stones and is currently working with their physicians to address this recurrent issue. LPAs observation on 5/15/2025 R1 has Home Health Aid providing bathing, cleaing, changing services 2X per week for 5.5 hours since mid April, 2025.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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 4
Control Number 21-AS-20250213151746
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: 05/15/2025
NARRATIVE
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Continued from LIC9099-A

Per complaint investigation 21-AS-20241113104034 Unsubstantiated investigation findings; 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 prei-care refusals at least 4 times between 10/14/2024 and 12/1/2024. Therefore allegations are Unsubstantiated.

Facility did not safeguard resident's personal belongings - Reporting party alleges residents laptop was stolen by staff during a period of hospitalization. Interviews and documents of emails with Administrator and staff revealed facility is following theft protocols. Per resident (R1) an investigation was conducted but the tablet was not located so they bought a new one. This allegation was previously reported to police November 2024, 24-09054 and determined allegation unfounded.

Based on record review, interviews conducted, and observations made, the allegations of Resident incontinent care needs not met and Facility did not safeguard resident's personal belongings 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 that alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.


No Deficiencies cited for complaint.

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

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250213151746
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: 05/15/2025
NARRATIVE
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Continued from LIC9099

Therefore allegation facility is not answering phone line (call bells) is Substantiated. LPA has delivered Substantiated findings on same allegation for 21-AS-20250210132414 today and cited. Therefore there will be no citations on this one.

Based on interviews conducted, observations made, and record review, the allegation listed above is SUBSTANTIATED. A finding that complaint allegations are substantiated means that the allegation is valid because the preponderance of the evidence standard has been met, therefore the allegation is SUBSTANTIATED.

Exit interview conducted. Copy of report discussed and provided to Licensee, whose signature on form confirms receipt of documents. Appeal Rights Provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4