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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 12:18:09 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
02/10/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250210132414
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:
10:30 AM
MET WITH:Agustin Samaniego, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff do not ensure resident receives adequate bathing services
Staff do not respond to resident call button requests in a timely manner
Staff do not ensure residents room is kept free of mal odors
INVESTIGATION FINDINGS:
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On 5/15/2025, Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above alligation and met with Agustin Samaniego, Administrator.

Staff do not ensure resident receives adequate bathing services- Complainant alleges staff do not provide adequate bathing services, is supposed to get bathed 2 times per week but the staff doesn’t ensure they are getting a full bath and will only get the top half of the body cleaned and on the other day they will only do the bottom half. Interview with Administrator informed when the resident has a shower a shower log is filled out by the staff. If there is no shower log, there was no shower. Records reviewed of R1’s Needs & Services Plan & Assessment indicate 2 person assist 2 times a week for bathing. LPA obtained shower log for time period of 10/28/2024 – 2/13/2025.

Continue on LIC9099-C
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 7
Control Number 21-AS-20250210132414
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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Continue from LIC9099

Shower logs from 11/1/2024 to 2/13/2025 documented R1 was only given 9 full showers, 4 logs indicating only feet or hair being washed, and 5 refusals in 3.5 months which amounts to less than then 1 bath per week and is less than the 2 baths per week indicated in R1’s admissions agreement. During investigation, LPA conducted interviews with residents’ and staff. On 12/6/2024 CCL conducted complaint 21-AS-20240930151325 investigation and found same allegations Substantiated. Based on interviews conducted, observations made, and record review, the allegation listed above is SUBSTANTIATED.

Due to previous citation of regulation 87464(f) (4) given on 12/6/2024 a $250 civil penalty will be assessed for repeat violation in less than 12 months.

Staff do not respond to call button requests in a timely manner- Complainant alleges when R1 presses their call button, and it takes a long time for a response. LPA conducted interviews with residents and staff. Interviews with Administrator and RSD indicated staff should respond to a residents call within 15 minutes. And although the call bell system has been updated with a few pendants replaced we have not decreased the response times as we would have liked. We have hired 5 new staff although 2, due to scheduling conflicts have left. Documents obtained confirmed that over a 1-month period (1/5/25 -2/20/25), R1 waited 15 minutes or more 94 times before receiving staff assistance, 14 of which were for wait times greater than 30 minutes, and 4 were for wait times greater than 60 minutes. On 12/6/2024 CCL conducted complaint 21-AS-20240930151325 investigation and found same allegation 87411 (a) Substantiated. Based on interviews conducted and record review, the allegation listed above is Substantiated.

Due to previous citation of regulation 87411(a) given on 12/6/2024 a $250 civil penalty will be assessed for repeat violation in less than 12 months.

Staff do not ensure residents room is kept free of mal odors- Complainant alleges staff will not tend to R1’s catheter care needs in a timely manner which causes the residents room to smell bad. LPA conducted facility visits on 2/20/2025 (with LPA Ethel Contreras) & 5/1/2025 on both days observing a strong mal odor in R1’s room, on second visit Administrator observed odor out into the hallway.

Continue on LIC9099-C

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: 2 of 7
Control Number 21-AS-20250210132414
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-C

R1 has external catheter care plan but is not being taken care of in an appropriate time. Per Staff (S1) the machine gets full, which can cause it to smell. From LPA’s observations & interviews There was sufficient information obtained to support violations occurred therefore the allegations are Substantiated.

A finding that complaint allegations are substantiated means that the allegations are valid because the preponderance of the evidence standard has been met, therefore the allegations are SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) 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.

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: 7 of 7
Control Number 21-AS-20250210132414
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2025
Section Cited
CCR
87464(f)(4)
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Basic Services 87464(f) (4) Personal assistance and care...as indicated in the pre-admission appraisal, with those activities of daily living such as...bathing….
This requirement was not met as evidenced by: Based on record review and interviews...
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Licensee to submit self-certification that staff will be trained on and facility will ensure that bathing and refusals are documented for the contracted number of baths indicated in residents' admissions agreements. Licensee to submit to CCL by POC due date of 5/16/2025.
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R1 received a documented 9 full baths over the course of 3.5 months, which amounts to approximately less than1 bath per week and is less than the 2 baths per week indicated in R1’s admissions agreement. This poses an immediate Health and Safety, and personal rights violation to clients in care.
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******Civil Penalties of $250. for repeat of violation
Type A
05/16/2025
Section Cited
CCR
87411(a)
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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…
This requirement was not met as evidenced by:
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Licensee to submit self-certification to CCL stating that all care staff have will be coached on the facility's call response requirements and procedures for triaging response when unable to respond personally. Licensee to submit this to CCL by POC due date of 5/14/2025
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Based on interviews and record review, facility did not ensure timely response to residents' calls for assistance in over 94 instances in an approximately 1-month time frame. This posed an immediate health, safety, and personal rights violation to residents in care.
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******Civil Penalties of $250 for repeat violation
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
02/10/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250210132414

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:
10:30 AM
MET WITH:Agustin Samaniego, AdministratorTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff do not ensure adequate dental hygiene care assistance is provided to resident in care
Staff do not ensure residents are kept in clean dry clothing at all times
Staff do not ensure residents catheter care plan is being followed
Staff do not have the ability to communicate with residents in care
INVESTIGATION FINDINGS:
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On 5/15/2025, Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint investigation findings regarding the above alligation and met with Agustin Samaniego, Administrator.

Staff do not ensure adequate dental hygiene care assistance is provided to resident in care – Complainant alleges staff don't provide resident with dental hygiene assistance and the resident requires help with brushing their teeth as they can't hold the toothbrush very well. Interview with S1 revealed there is no teeth cleaning log/check list, like bathing. LPA obtained R1’s Needs and Service plan and per review states standby assistance for grooming but does not address assistance with brushing R1’s teeth. LPA conducted facility visits on 2/20/2025 & 5/1/2025 and observed R1 to having adequate hygiene. There was no information obtained that a violation occurred. LPA discussed regulation with staff.
Based on interviews, record/document reviews, and related information obtained during the investigation the allegation Staff do not ensure adequate dental hygiene care assistance is provided to resident in care is UNSUBSTANTIATED. 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: 5 of 7
Control Number 21-AS-20250210132414
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-C

Staff do not ensure residents catheter care plan is being followed & Staff do not ensure residents are kept in clean dry clothing at all times – Complainant alleges staff will not tend to the resident’s catheter care needs in a timely manner. R1 is a two person assist for toileting. Interviews conducted revealed R1 gets assistance daily with toileting and external catheter care. Documents obtained revealed R1 does have an external catheter. Complainant alleges staff will leave the resident for over an hour in there soiled diapers when they press the call button to be changed. Interviews conducted revealed R1 uses two different devices to stay dry and is kept in dry clothing at all times. LPA conducted facility visits on 2/20/2025 & 5/1/2025 and observed R1 to having adequate hygiene. There was not sufficient information obtained to support a violation occurred. Therefore, the allegations Staff do not ensure residents catheter care plan is being followed and Staff do not ensure residents are kept in clean dry clothing at all times are UNSUBSTANTIATED.

Staff do not have the ability to communicate with residents in care- Complainant alleges night staff don't speak any English and the residents can't communicate with them. LPA was able to conduct 4 out of 5 NOC shift staff interviews and was able to communicate with all of them. Interview conducted with R2 revealed, they had not had any issue communicating with any staff on any shift. Per investigation there was not sufficient information obtained to support a violation occurred. Therefore, the allegation Staff do not have the ability to communicate with residents in care is UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore, the allegations are UNSUBSTANTIATED.

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: 6 of 7
Control Number 21-AS-20250210132414
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2025
Section Cited
CCR
87625(b)(3)
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87625(b)(3) Managed Incontinence
(b)In addition to Section 87611, General .., the licensee shall be responsible for :(3)Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by
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Licensee to ensure an in-service is conducted with all staff regarding incontinent care services to residents. Submit sign in & dated sheet for training with all staff with indicated training on top along with plan of future compliance with this regulation, ...
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Based on statements and observation, this requirement is not met as evidenced by: On 2/20/25 LPAs & 5/1/2025 LPA & Administrator observed R1’s room having strong incontinence odors. This poses a potential health & safety risk to R1, & other residents in care.
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, ensuring staff are checking on residents and changing residents timely & staff are keeping facility free of odors from incontinence. Submit proof of training by 5/30/2025 to clear citation.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7