486803710-12-10-2024-21-AS-BMOS-DBZRGX-20241216120124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 12/06/2024
Date Signed: 12/10/2024 04:13:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
09/30/2024 and conducted by Evaluator Julie Florio

COMPLAINT CONTROL NUMBER: 21-AS-20240930151325

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: 69	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Agustin Samaniego, Executive Director		TIME COMPLETED:	04:27 PM

ALLEGATION(S):

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Staff did not notify resident’s responsible party of an incident.
Staff are not providing adequate food services to residents.

INVESTIGATION FINDINGS:

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On 12/06/2024, at approximately 4:00 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver findings for the above allegations. Reporting Party (RP) alleges that staff did not notify Resident 1’s (R1’s) responsible party of an incident and that staff are not providing adequate food services to residents which are both UNSUBSTANTIATED.

LPA conducted 10-day on 10/02/2024 for complaint #21-AS-20240930151325 which was received by The Department on 09/30/2024 and made observations, conducted interviews, and obtained documents. LPA was able to interview Resident 2 (R2), Resident 3 (R3), and the Resident Services Director (RSD) which revealed that R1’s responsible party was notified of the incident in question. Documents obtained confirmed that R1’s daughter, not R1’s spouse, was listed as the responsible party, and was notified of the incident as required.

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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-20240930151325

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING	FACILITY NUMBER: 486803710
	VISIT DATE: 12/06/2024

NARRATIVE

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Continued from LIC9099...

Additionally, interviews with Resident 2 (R2), Resident 3 (R3), and the Resident Services Director (RSD) provided conflicting information regarding staff not providing adequate food services to residents. Upon review of facility menus and R2 and R3’s physician’s reports and care plans, staff are providing adequate food services to residents.

Based on interviews conducted, observations made, and record review, the allegations listed above are UNSUBSTANTIATED. A finding that complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report discussed and provided to Licensee. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Julie Florio	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

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