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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 10/31/2025
Date Signed: 10/31/2025 11:08:01 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
07/03/2025 and conducted by Evaluator Ali Deniz
COMPLAINT CONTROL NUMBER: 21-AS-20250703131124
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:
10/31/2025
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Agustin SamaniegoTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Unqualified staff provide medical care to residents
Facility staff administering medication without physician orders
INVESTIGATION FINDINGS:
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At approximately 09:30 AM, Licensing Program Analyst (LPA) Deniz arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Administrator, Agustin Samaniego

During the course of the investigation, the Department requested and reviewed documents, conducted interviews, and made observations. The following allegations were investigated: “Unqualified staff provide medical care to residents” and “Facility staff administering medication without physician orders.”
The complaint alleged that Medication Technicians (Med Techs) were being directed to check residents’ blood sugar levels and administer insulin injections. The complainant stated that these procedures are typically performed by licensed nursing staff, due to the clinical skills required to safely administer injections and monitor for potential complications.
During the investigation, LPA conducted interviews with 4 staff members. 2 out of 4 staff members confirmed that Med Techs, who are not licensed nurses, administer insulin injections to residents. One staff member stated that Med Techs had been advised by facility management to administer insulin.
Continued on LIC9099-C page...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
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-20250703131124
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: 10/31/2025
NARRATIVE
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Continued from LIC9099 page...

LPA also conducted interviews with 5 residents which 4 out of 5 receive insulin injections. 3 out of 4 residents confirmed that Med Techs administer their insulin injections. A review of resident Medication Administration Records (MARs) revealed that all identified residents receiving insulin had documentation indicating insulin administration. The MAR review also identified discrepancies, including medications not initialed as administered.
Based on information obtained through staff and resident interviews, record reviews, and observations, the evidence supports that unqualified staff were performing insulin injections, which is outside their approved scope of practice. Documentation errors were also observed in the Medication Administration Records (MARs). Therefore, the allegations are Substantiated. A finding that a 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 deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC9099-D (Deficiency Page), Plan of Corrections, and Appeal Rights discussed and provided to Executive Director/Administrator. Signature on form confirms receipt of documents.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Ali Deniz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250703131124
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: 10/31/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2025
Section Cited
CCR
87629(a)
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87629(a) Injections - The licensee shall be permitted to accept or retain a resident who requires ... injections if the injections are administered by the resident or by an appropriately skilled professional. This requirement is not met as evidenced by:
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Administrator agrees to submit a plan of future compliance about how facility will handle the insulin injections & drawing by 11/03/2025 and conduct in-service staff training regarding Injections and medication administration to CCL by POC date of 11/11/2025
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Based on interviews, observation, and record reviews, the facility failed to ensure that only qualified and trained personnel provided medical care and administered medications to residents, as required. This poses an immediate health, safety or personal rights risk to persons 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: 10/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2025
LIC9099 (FAS) - (06/04)
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