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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 12/09/2022
Date Signed: 12/09/2022 11:43:37 AM

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
09/09/2022 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 21-AS-20220909172249
FACILITY NAME:PARAMOUNT HOUSE SENIOR LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:REMIGIO, RICHARDFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 84DATE:
12/09/2022
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Activities Director, Kathy PawlakTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff did not inform resident's authorized person of an incident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Paramount House Senior Living for the purpose of delivering complaint findings. LPA was greeted at the door by Activities Director, Kathy Pawlak, and was granted access into the facility.

During the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties and witnesses.

Complaint alleges that Facility staff did not inform resident's authorized person of an incident. Based on interviews that were conducted and a review of facility documents, LPA was able to confirm that facility did not report the incident to Community Care Licensing in a timely manner, nor did they notify the Responsible Parties of the residents that there was a facility wide medication error due to insufficient staffing.

(Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
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-20220909172249
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: 12/09/2022
NARRATIVE
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Furthermore, the incident occurred on September 5, 2022 and Community Care Licensing did not receive the incident report until September 7, 2022 (See LIC 9099D).

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with the Activities Director and a copy of this report along with appeal rights were emailed due to printer issues.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20220909172249
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: 12/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2022
Section Cited
CCR
87211(a)(2)
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87211(a)(2) Reporting Requirements:
(a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.

This requirement was not met as evidenced by:
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Licensee/Administrator shall conduct staff training regarding Reporting Requirements. In addition, Licensee/Administrator shall provide a written statement on how future compliance will be met and adhered to regarding this regulation.
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Based on interviews that were conducted, facility documents reviewed and an incident occurring on September 5, 2022 between the hours of 1600-2200 hours and reported to licensing on September 7, 2022, LPA was able to confirm that facility did not report the incident to Community Care Licensing in a timely manner nor did they notify the Responsible Parties of the incident that occurred.
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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.
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan SarangiTELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3