<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803710
Report Date: 08/18/2023
Date Signed: 08/18/2023 05:04:14 PM


Document Has Been Signed on 08/18/2023 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
486803710
ADMINISTRATOR:REMIGIO, RICHARDFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 67DATE:
08/18/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:31 PM
MET WITH:Candace Moses, AdministratorTIME COMPLETED:
05:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/18/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on an incident report submitted by the facility regarding a resident (R1) who had been hospitalized due to unknown cause of burns. Incident report indicated that R1 had contacted their family member during overnight hours to provide transportation to a medical center after sustaining burns to their face. Based on a review of resident records, R1 was previously independent and considered a "level 0" in terms of care and only required reminders to complete tasks. The facility had been contacted by R1's Home Health agency that R1 was admitted to the hospital and assisted by R1's daughter without R1 notifying the facility.

LPA spoke with Administrator and Health Services Director regarding corrective actions following the incident. Facility has discussed house policies with R1 and R1's partner both residing in shared room and issued a formal letter notice to comply with house rules regarding smoking in designated smoking areas outside of the facility. Notice of eviction if house policies are not followed was included in the letter. Facility has updated R1's level of care by providing assistance with medication administration and routine two hour room checks. In addition facility has updated R1's Physician's Report indicating that they are not allowed to leave the facility unassisted. LPA and Health Services Director discussed further plan of action for increased monitoring on R1 to determine behaviors of smoking. Administrator agrees to contact R1's Primary Care Physician to determine if R1 is able to have access to smoking considering the use of oxygen.

No deficiencies cited.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1