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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 06/19/2025
Date Signed: 06/19/2025 10:11:27 AM

Substantiated


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
06/02/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20250602154555
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: 82DATE:
06/19/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:ED, Agustin Samaniego TIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Staff is providing care beyond the scope of the license
INVESTIGATION FINDINGS:
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At approximately 09:30AM, Licensing Program Analysts (LPAs) Deniz and Felias arrived unannounced to deliver findings regarding a Complaint Investigation regarding the above allegations and met with Executive Director/Administrator, Agustin Samaniego.
During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. There is an allegation that “staff is providing care beyond the scope of the license.” Complainant alleged that Staff Member 1 (S1) was providing care such as fecal impaction removal, suppository insertion, and medicated cream administration to residents that they did not have training for. Complainant stated that S1 was a caregiver and did not have skilled professional training or medication technician training.
On 06/05/2025, LPAs received information from the facility stating that an internal investigation was conducted regarding the complaint allegation. Per the information provided, the facility found that S1 was
Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
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 3
Control Number 21-AS-20250602154555
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: 06/19/2025
NARRATIVE
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Continued from LIC9099...

requested by Resident 1 (R1) to assist with applying a suppository and ointment and that S1 complied with R1’s request. Facility submitted an incident report to Community Care Licensing (CCL) on 06/06/2025 detailing the incident.
Based on document review and observations made, this Allegation is Substantiated. A finding that the Complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC9099D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250602154555
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2025
Section Cited
CCR
87622(b)(1)
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87622 Fecal Impaction Removal, Enemas, and/or Suppositories (b)... the licensee shall be responsible for the following: (1) Ensuring that the administration of enemas or suppositories or manual fecal impaction removal is performed by an appropriately skilled professional...This requirement was
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Licensee agrees to submit in-service training for all facility care staff reviewing suppository care and job duties. Licensee to submit to CCL by POC due date of 6/30/2025.
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not met as by evidenced by: based on interviews and record review, Licensee did not comply with the section cited and did not ensure that a skilled medical professional provided a suppository/manual fecal impaction for R1. This poses an potential health and safety risk to residents in care.
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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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3