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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486803710
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:03:13 PM


Document Has Been Signed on 03/21/2024 04:03 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:CANDICE MOSESFACILITY TYPE:
740
ADDRESS:2061 PEABODY RDTELEPHONE:
(707) 455-0300
CITY:VACAVILLESTATE: CAZIP CODE:
95687
CAPACITY:95CENSUS: 64DATE:
03/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:01 PM
MET WITH:Candace Moses, AdministratorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 3/21/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced and was greeted by Administrator, Candace Moses. The purpose of the case management visit is to address separate violations found during complaint investigation regarding complaint number 21-AS-20231129102127.

LPA toured the facility, reviewed resident and facility records, interviewed staff and outside parties and made observations. LPA found that on 11/22/2023, staff responded to resident, (R1) observing that R1 had been unattended in their wheelchair for several hours. R1's narrative charting notes indicate that staff attempted to assist R1 to bed on 11/22/2023 at approximately 3:00am. The same day on 11/22/2023, R1 had contacted staff using the bedroom wall call bell system. R1 was found to be sitting in their wheelchair from a recorded time of 3:00am - 3:56pm and covered in urine. Upon a review of R1's care plan, it is indicated that R1 requires a two-person assist for transfers as well as 2 hour room checks. Incident report and charting notes confirm that R1 had been left in their wheelchair for a substantial amount of hours. The facility is unable to prove that staff were providing adequate supervision and conducted proper room checks for R1.

Deficiency 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. Appeal Rights given.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/21/2024 04:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2024
Section Cited
CCR
87464(b)

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87464(f) - Basic services shall at a minimum include care and supervision as described in
Health and Safety Code section 1569.2(c). These requirements were not met as evidenced by: Based on review of records, R1 was found to be left unattended and soiled in their wheelchair for several hours.
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Facility failed to ensure basic services and proper care and supervision was provided to resident in care. Administrator agrees to conduct in-service training for all staff to follow facility care protocols on routine room checks and meeting residents' care and supervision needs.
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This serves as a potential health & safety risk to residents in care.
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Signed training to be submitted to CCLD by POC date 4/4/2024.

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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: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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