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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 02/16/2021
Date Signed: 02/16/2021 06:35:00 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2020 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20201019132325
FACILITY NAME:PARAMOUNT HOUSE SENIOR LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:SIOBHAN LEHMANFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 75DATE:
02/16/2021
UNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Siobhan Lehman, AdministratorTIME COMPLETED:
06:25 PM
ALLEGATION(S):
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Facility is short staffed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tobola conducted a complaint investigation regarding the above allegations. Due to COVID-19 restrictions LPA Tobola met with Administrator Siobhan Lehman by tele-visit. Facility was toured, records were reviewed and interviews with staff and residents were conducted.

Complaint alleges that facility is short staffed. Upon a tour of the facility and a review of the staff time sheets it was determined that the facility had insufficient staffing on several dates between 10/11/2020 - 10/24/2020.

The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2020 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20201019132325

FACILITY NAME:PARAMOUNT HOUSE SENIOR LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:SIOBHAN LEHMANFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 75DATE:
02/16/2021
UNANNOUNCEDTIME BEGAN:
03:22 PM
MET WITH:Siobhan Lehman, AdministratorTIME COMPLETED:
06:25 PM
ALLEGATION(S):
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5
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7
8
9
Facility not providing adequate services to resident.
INVESTIGATION FINDINGS:
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5
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7
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9
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12
13
Licensing Program Analyst (LPA) Tobola conducted a complaint investigation regarding the above allegation. Due to COVID-19 restrictions LPA Tobola met with Administrator Siobhan Lehman by tele-visit. Facility was toured, records were reviewed and interviews with staff and residents were conducted.

Complaint alleges that facility is not providing adequate services to resident. Based on interviews with staff and residents LPA received conflicting information, therefore allegation is found to be UNSUBSTANTIATED meaning that although the allegations may have happened, there is not a preponderance of evidence to prove that the allegations occurred.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Hope DeBenedettiTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20201019132325
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING
FACILITY NUMBER: 486803710
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
02/17/2021
Section Cited
CCR
87411(a)
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**Amended**
87411(a) Personnel Requirements Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met based on evidence by:
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Administrator failed to ensure number of staffing was sufficient. Administrator agrees to submit a statement to CCL acknowledging the facility's responsibility to provide sufficient staffing supervision over clients at all times.
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Based on interviews and records review it was found that the facility did not ensure the number of staffing was sufficient in multiple dates between 10/11/2020 - 10/24/2020 which poses an immediate health and safety risk for clients in care.
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Administrator will submit a written plan and staff schedule showing how they will ensure that there is sufficient staff at the facility by POC due date 2/17/2021.
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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: Kimberley MotaTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3