486803710-12-30-2024-21-AS-RFRK-DCG3KM-20241230171921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803710
Report Date: 12/30/2024
Date Signed: 12/30/2024 05:19:33 PM

Document Has Been Signed on 12/30/2024 05:19 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR/ DIRECTOR:	SAMANIEGO,AGUSTIN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY: 95	TOTAL ENROLLED CHILDREN: 0	CENSUS: 70	DATE:	12/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Agustin Samaniego, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 12/30/2024, Licensing Program Analysts (LPAs) Frank and Felias conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Administrator, Agustin Samaniego and Resident Services Director, Elizabeth Aguiar. The facility is a one story building licensed for 95 non-ambulatory and 5 bedridden residents, along with a hospice waiver capacity of 10 and hospice exceptions granted for 7. The facility currently provides care for 70 residents,16 of which are receiving hospice services and a dedicated memory care unit. LPAs continued with a tour of the facility with Administrator, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be last charged on 5/15/2024 at the time of visit. Both smoke detectors and sprinkler/alarm systems throughout the facility were interconnected, and inspected by an outside agency with current certification dated 3/18/2024. Additional carbon monoxide detectors located in both assisted living and memory care sections of the facility were also found to be in working order. The Vacaville Fire Department conducted their annual inspection on 11/24/2024 and found no violations. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations with food delivered twice per week. Food stored in the kitchen were properly stored as per regulations on this day at the time of the visit. Facility closely monitors resident diets with appropriate dietary restrictions posted on kitchen bulletin board. Toxins are stored in designated facility storage closets located throughout the facility. During inspection LPAs observed both a storage room and a laundry room containing cleaning supplies in the assisted living section of the facility to be open. Only the laundry room had housekeeping staff nearby. No residents were observed in the area at the time. LPAs discussed concerns with the Administrator and the laundry room was immediately secured. Technical Violation issued. continued on 809-C.

Victoria Bertozzi	TELEPHONE: (707) 588-5059
Robert Frank	TELEPHONE: (707) 588-5026
	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/30/2024

NARRATIVE

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...continued from 809
There was a supply of hygiene products and paper products available for residents. All resident’s apartments have lighting & appropriate furnishings. Water was measured at faucets in several residents private bedrooms and measured between 112.1 and 117.1 degrees F which is within regulation. Medications were located in medication room in assisted living and within a designated medication cart in the memory care unit and were found to be secured. LPAs conducted a spot check of medications and found all administering to be in order. During the tour, residents were observed interacting with staff in common spaces, resting in their private bedrooms, participating in various activities with Activities Director and mingling in the dinning hall with family and amongst each other. Residents are visited by family frequently and interact with one another in the dining area, common spaces as well as in resident private apartments. The facility provides an eclectic range of activities specified for both assisted living and memory care engagement. There is an ample amount of outdoor space and seating for residents on the front corridor and center patio for additional leisure.

LPAs conducted a sample file review for staff. During review LPAs observed that a staff member (S1) was not showing the correct amount of training hours required and not having completed a First Aid course. A second staff member (S2) did not have First Aid Training. Technical Violation issued. All other staff members have appropriate documentation on file. LPAs also conducted a file review for residents. Upon review, LPAs found residents to have appropriate documentation on file including Service Plans and Physician's Reports.

LPAs requested the following documents be sent to CCL by COB 1/30/2025:

LIC 308 Designated Facility Responsibility
LIC 610 Emergency Disaster Plan
Liability Insurance

No deficiencies cited during today's visit. Exit interview conducted. Copy of report and LIC9102 (Technical Violations/Advisories) discussed and provided to Resident Services Director. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Robert Frank	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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