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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 04/18/2024
Date Signed: 04/18/2024 04:18:32 PM

Substantiated


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
01/22/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240122214950
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: 69DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Candace Moses, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Facility did not ensure a safe environment
Facility not kept clean, safe and sanitary
INVESTIGATION FINDINGS:
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On 4/18/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Candace Moses. LPA Tobola conducted a tour of the facility, gathered photo evidence and written statements interviewed staff, reviewed facility medication records and made observations.

Complaint alleges facility did not ensure a safe environment due to an incident involving outside unhoused individuals (I1) having access to the facility. Based upon interviews with Administrator and staff (S2 & S4) LPA confirmed that although undetermined how I1 gained access inside the facility, it was confirmed that an incident did occur where several unhoused individuals were observed in the common kitchen and lounge area during evening hours, which is an immediate safety risk to residents in care.

Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
01/22/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 21-AS-20240122214950

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: DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Candace Moses, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not providing adequate care and supervision to the residents
INVESTIGATION FINDINGS:
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5
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7
8
9
10
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13
On 4/19/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Administrator, Candace Moses. LPA Tobola conducted a tour of the facility, gathered photo evidence and written statements, interviewed staff and outside parties and made observations during the course of the investigation.

Complaint alleges staff are not providing adequate care and supervision to the residents. Upon multiple facility visits and inspections of resident bedroom, LPA did not observed residents to be left unattended or staff neglecting resident care needs. Based on information provided by outside parties, there is inconsistent information regarding resident (R1) and facility meeting their activities of daily living. In addition, based upon interviews with multiple staff (S1,S2,S3 & S4), LPA was provided contradicting statements to staff meeting client care needs. Due to a lack of corroborating evidence, the allegation is found to be unsubstantiated.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240122214950
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: 04/18/2024
NARRATIVE
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A finding that the complaint allegation, staff are not providing adequate care and supervision to the residents is unsubstantiated meaning that although the allegation 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 allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240122214950
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: 04/18/2024
NARRATIVE
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Complaint alleges facility not kept clean, safe and sanitary. Upon interviews, photo evidence and written statements from outside parties, LPA found that the facility failed to ensure resident’s (R1) bedroom was kept clean, safe and sanitary after it was found that R1’s bedside commode had not been properly disposed of in a timely manner which is a potential health & safety and personal rights risk to residents in care.

Allegations, facility did not ensure a safe environment and facility not kept clean, safe and sanitary are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240122214950
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/19/2024
Section Cited
HSC
1569.269
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(5) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.

This was not met as evidence by:**
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Licensee has implemented updated protocols on securing the facility parameters after business hours from outside of faciliyt. A copy of the protocol/plan of action to be submitted to CCLD by POC date 4/19/2024.
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Based on interviews with Administrator and staff (S2 & S4), it was confirmed that an incident occurred in which several unhoused individuals gained access into the facility which serves as an immediate health & safety risk to residents in care.
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Type B
04/25/2024
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This was not met as evidence by:**
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Licensee has implemented a 2 hour room check for resident (R1) ensuring staff are providing a clean, safe and sanitary living environment. Copy of the room check template to be provided to CCLD by POC due date 4/25/2024.
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Based upon LPA observation, photo evidence and written statements from outside parties, LPA found that staff failed to on one or more occasion, ensure resident (R1) commode was cleaned in a timely manner. This serves as a potential health & safety risk to residents in care.
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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: 04/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5