486803710-2-14-2023-21-AS-HDBI-CP53CU-20230216170829

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 02/14/2023
Date Signed: 02/14/2023 10:40:14 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
02/13/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230213120159

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	REMIGIO, RICHARD		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS: 80	DATE:	02/14/2023
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator, Richard Remigio		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff do not distribute residents' medications as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Paramount House Senior Living for the purpose of opening a complaint and conducting a complaint investigation. LPA was greeted at the door by, Administrator, Richard Remigio, and was granted access into the facility.

During the opening of the complaint investigation inspection on February 14, 2023 and during the course of the investigation on this date, LPA reviewed a random sample of Medication Assessment Records (MARs)/Community Dashboard, interviewed staff, resident(s) in care and reviewed the staff schedule for February 2023.

Complaint alleges that Staff do not distribute residents medications as prescribed. During the course of the investigation, LPA interviewed staff and residents. LPA learned that the missed medications happened when agency staff was on the floor at the facility. In addition, LPA received and reviewed the Physician Orders and the Medication Assessment Records/Community Dashboard for three residents (Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230213120159

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: 02/14/2023

NARRATIVE

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with facility Med Tech #1 and the Administrator and confirmed the medications that were supposed to be administered were missed on February 1, 2023 and February 3, 2023 which presents a health, safety and personal rights risk to residents in care.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Civil Penalties were assessed today. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in additional civil penalties. Exit interview was conducted with the Administrator and appeal rights were given to the Administrator.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230213120159

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: 02/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/15/2023 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465(a)(5)-Incidental Medical and Dental Care The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator shall draft a Plan of Correction (POC) to include staff training with a sign-in sheet along with a written statement on how future compliance will be met.
	8 9 10 11 12 13 14	Based on an interviews with staff and residents, review of the physician orders and Medication Assessment Record (MAR) dated for February 3, 2023 agency staff was on the floor and failed to distribute the medication to residents in care which presents an immeidate health, safety and Personal Rights risk to the residents in care.	8 9 10 11 12 13 14	This Plan of Correction (POC) is due February 15, 2023. Civil Penalty Assessed
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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 DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023

LIC9099 (FAS) - (06/04)

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