486803710-10-26-2023-21-AS-DTOA-CWYW5E-20231026165901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 486803710
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:59:06 PM

Document Has Been Signed on 10/26/2023 04:59 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 LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	REMIGIO, RICHARD		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS: 68	DATE:	10/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:56 AM
MET WITH:	Candace Moses, Administrator		TIME COMPLETED:	05:15 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 10/26/2023, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and was greeted by Administrator, Candace Moses. The facility is a one story building licensed for 95 non-ambulatory and 5 bedridden residents, along with a hospice waiver capacity of 10. The facility currently provides care for 68 residents, 6 of which are receiving hospice services and a dedicated memory care unit. LPA 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 2/17/2023 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 8/24/2023. Additional carbon monoxide detectors located in both assisted living and memory care sections of the facility were also found to be in working order. Auditory alarms for residents in care with dementia were tested and fully functioning. 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. Toxins are stored in designated facility storage closets located throughout the facility. During inspection LPA observed a laundry room containing cleaning supplies in the assisted living section of the facility to be open with housekeeping staff nearby. No residents were observed in the area at the time. LPA discussed concerns with housekeeping staff & Administrator and the laundry room was immediately secured. Technical Violation issued. 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. Continued onto LIC809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING	FACILITY NUMBER: 486803710
	VISIT DATE: 10/26/2023

NARRATIVE

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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. LPA conducted a spot check of medications and found all administering to be in order. LPA observed one medication start date not properly input on the Centrally Stored Medication Record but was indicated on the medication container. LPA discussed corrections with Medtech staff requesting for record review and audit. Technical Advisory issued. 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 dinning 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. Single facility bus was inspected and found to be adequately equipped with fire extinguisher and first aid kit.

LPA conducted a sample file review for staff and found staff to have 1st Aid & CPR training conducted on Relias. During review LPA found staff (S1 & S2) in need of additional 40-hour onboard training. Technical Violation issued. LPA discussed corrections with Business Office Director who will provide LPA with updated completed training for S1 & S2. Facility is to conduct review of all staff annual training and schedule accordingly for completion. LPA also conducted a file review for residents. Upon review, LPA found residents to have appropriate documentation on file including Service Plans and Physician's Reports.

Administrator, Candace Moses's Administrator Certification 6026408740 is currently pending for renewal. The Department has received confirmation of the payment and training as of 7/13/2023.

LPA requested the following documents be sent to CCL by COB 11/26/2022:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 10/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023

LIC809 (FAS) - (06/04)

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