486803710-12-14-2023-21-AS-VBEI-CYNQAK-20231219110004

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 12/14/2023
Date Signed: 12/14/2023 03:10:52 PM

Unsubstantiated

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
12/12/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20231212110238

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	CANDICE MOSES		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS:	DATE:	12/14/2023
		UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Candace Moses, Administrator		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff will not allow resident to return to the facility

INVESTIGATION FINDINGS:

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On 12/14/2023, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating and delivering complaint investigation findings and was greeted by Administrator, Candace Moses. LPA interviewed staff and outside parties, gathered facility and resident medical records and made observations.

Complaint alleges staff will not allow resident (R1) to return to the facility. Based on record review and interviews with Administrator and outside parties, it was found that R1 had returned to the facility from a medical center on 12/12/2023. The same day on 12/12/2023, R1 was sent out for medical attention due to symptoms of clostridium difficile (C-diff). R1 was found to be diagnosed for C-diff by medical center staff on 12/7/2023. However, based on a review of R1's discharge paperwork, although medical instructions for C-diff medication was included in the discharge packet, the diagnosis was not listed on the discharge summary packet for facility notification. Facility was not properly informed of R1 condition. In addition, C-diff is considered a prohibited health condition based on Title 22 Regulations and requires proper exception documentation for the facility to retain resident R1.
Continued onto LIC9099-C

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: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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-20231212110238

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: 12/14/2023

NARRATIVE

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The facility followed regulation protocols for approved exception ensuring resident is safely discharged back to the facility's care. Due to conflicting information and a lack of corroborating evidence the allegation is found to be unsubstantiated. Allegation, staff will not allow resident to return to the facility is UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited during visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC9099 (FAS) - (06/04)

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