486803710-6-8-2021-21-AS-KMOA-C48NWL-20210622104944

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 06/08/2021
Date Signed: 06/08/2021 02:04:38 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
01/21/2021 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20210121164225

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	SIOBHAN LEHMAN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS: 78	DATE:	06/08/2021
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Siobhan Lehman, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff mismanaging resident's medication
Staff is not meeting resident's needs
Staff did not follow emergency protocols

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tobola conducted a visit gather additional information for the complaint investigation and met with Administrator Siobhan Lehman. LPA toured the facility, conducted a medication review, gathered facility files and interviewed staff and outside parties.

Complaint alleges staff are mismanaging resident's medication. Based on a sample resident medication count for 3 of 3 residents LPA observed each medication pill counted and found that the physical count matched the Medication Administration Records counts for 3 of 3 residents. However, LPA received conflicting information based on interviews with staff, residents and outside parties, meaning the allegation is found to be UNSUBSTANTIATED.

Continued onto LIC9099-C
Signatures on file

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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-20210121164225

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
	VISIT DATE: 06/08/2021

NARRATIVE

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Complaint alleges staff is not meeting resident's needs. Based on interviews with residents, staff and outside parties LPA received contradicting information related to the allegation. LPA conducted a tour of the facility and did not observe any residents not being provided adequate care. Based on LPA observations and receiving contradicting information from interviews with staff, residents and outside parties, the allegation is UNSUBSTANTIATED.

Complaint alleges staff S1 did not follow emergency medical protocols during an emergency disaster incident. Based on interviews with staff, residents and outside parties LPA found that there was an incident in January 2021 causing the facility smoke alarms to activate which required partial evacuation and fire department contact. LPA did not receive corroborating evidence that staff S1 was not following emergency protocols during the incident. However, LPA received conflicting information based on interviews with staff, residents and outside parties, meaning the allegation is found to be UNSUBSTANTIATED.

A finding that the complaint allegations staff mismanaging resident's medication, staff is not meeting resident's needs and staff did not follow emergency protocols are unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Appeal Rights Given.

Signatures on file.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC9099 (FAS) - (06/04)

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