486803710-3-21-2024-21-AS-KMOA-D3ZMWG-20240404095820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 03/21/2024
Date Signed: 03/21/2024 04:09:52 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
11/29/2023 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20231129102127

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: 64	DATE:	03/21/2024
		UNANNOUNCED	TIME BEGAN:	01:48 PM
MET WITH:	Candace Moses, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Neglect/Lack of Care and Supervision resulted in resident being hospitalized

INVESTIGATION FINDINGS:

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On 3/21/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Candace Moses. LPA toured the facility, reviewed resident and facility records, interviewed staff and outside parties and made observations.

Complaint alleges neglect/lack of supervision resulted in resident (R1) being hospitalized. Based on interviews with outside parties and facility staff, LPA received contradicting information with not enough corroborating information pertaining to the allegation. Upon review of R1's narrative charting records it was indicated that on 1/22/2023, R1 had been observed in their wheelchair located in their bedroom from approximately 3:00am-3:56pm. Charting records also indicated that R1 had refused assistance and medical services from the facility prior to being discovered. Based on R1's Needs & Service Plan, R1 requires a two-person assist when transferring from their wheelchair. LPA requested to contact R1 for statement but LPA was informed that R1 was not willing to speak. In addition, LPA was unable to confirm if the incident and alleged neglect involving R1 directly caused R1's hospitalization. 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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231129102127

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: 03/21/2024

NARRATIVE

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Allegation, neglect/lack of supervision resulted in resident being hospitalized 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. Appeal Rights Given.

No deficiencies cited.

On 3/21/2024, LPA initiated a separate Case Management Visit to issue citation for general lack of supervision and failure to provide basic services to resident R1 after R1 had been observed in their wheelchair unassisted for a substantial amount of hours.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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