486803710-4-10-2023-21-AS-HDBI-CQTV6D-20230412160922

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 04/10/2023
Date Signed: 04/10/2023 02:08:42 PM

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
02/22/2023 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20230222150514

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: 79	DATE:	04/10/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Memory Care Director, Niila Paulin		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Oxygen Administration-Oxygen not being used accordingly
Neglect/Lack of Supervision
Physical plant

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 Memory Care Director, Niila Paulin 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. LPA reviewed facility records and resident records.

Complaint alleges that Oxygen Administration-Oxygen not being used accordingly. During the course of the investigation, LPA interviewed staff and an outside provider and learned that the oxygen was supposed to be turned on. However, staff did not check to see if the resident’s oxygen tank was turned on before resident left the facility. (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: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

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-20230222150514

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: 04/10/2023

NARRATIVE

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Furthermore, an outside provider confirmed that the resident presented with the oxygen tank not being turned on (See LIC 9099D). During communications with the Administrator on April 5, 2023, Administrator disclosed In-Service training was conducted with staff (See LIC 812-Email-Communication with Administrator dated for April 5, 2023).

Complaint alleges that Neglect/Lack of Supervision. During the course of the investigation, facility documents including call bell logs were reviewed. LPA learned during a document review of the call bell log dated for March 10, 2023 that the facility had multiple instances in January 2023 of a resident having to wait an excessive amount of time to be responded too. Furthermore, during an interview with the Administrator dated for March 14, 2023, LPA learned that response times can take longer during bedtime. LPA educated the Administrator regarding the importance of responding to call bells in a timely manner (See LIC 9099D).

Complaint alleges Physical Plant. During the course of the investigation, LPA toured Resident #1’s room on March 27, 2023 (See LIC 812- Observation/Photo of Resident #1's closet), LPA observed a rat trap inside Resident #1’s closet. LPA interviewed the Maintenance Director on March 27, 2023 and learned that rats have been creating a mess in the closet and that this has been going on for about a month now and that Terminix has been out at the facility to treat the facility grounds (See LIC 9099D).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Memory Care Director.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230222150514

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: 04/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/11/2023 Section Cited CCR 87618(b)(5)	1 2 3 4 5 6 7	87618(b)(5)Oxygen Administration - Gas and Liquid: In addition to Section 87611(b), the licensee shall be responsible for the following: (5) Ensuring that facility staff have knowledge of, and ability in the operation of the oxygen equipment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall include a Plan of Correction (POC) regarding staff training and future compliance regarding this regulation.
	8 9 10 11 12 13 14	Based off of interviews that were conducted, it was disclosed that the resident did not have the oxygen turned on during transportation to an appointment. Resident presented to the outside provider with the oxygen tank not being turned on. This presents an immediate risk to the health, safety and personal rights risk to the residents in care.	8 9 10 11 12 13 14
Type A 04/11/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a) Personnel Requirements - General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee shall include a Plan of Correction (POC) regarding staff training and future compliance regarding this regulation.
	8 9 10 11 12 13 14	Based on facility documents reviewed LPA was able to confirm facility had multiple instances in January 2023 of a resident having to wait an excessive amount of time to be responded too which presents an immediate health, safety and personal rights risk to the residents in care.	8 9 10 11 12 13 14

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: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230222150514

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: 04/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/17/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not as evidenced by:	1 2 3 4 5 6 7	Licensee shall include a Plan of Correction (POC) regarding ridding the room of rats and ensuring that there are no rats. In addition, Licensee shall provide a statement on how future compliance will be met.
	8 9 10 11 12 13 14	Based off of observation that was conducted on March 27, 2023, LPA observed a rat trap inside Resident #1’s closet which presents a potential health, safety and personal rights risk to the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 04/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023

LIC9099 (FAS) - (06/04)

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