486803710-6-3-2021-21-AS-KMOA-C56THT-20210722144510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 06/03/2021
Date Signed: 06/03/2021 05:42:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/19/2021 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20210219144353

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	SIOBHAN LEHMAN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS: 78	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Siobhan Lehman, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not follow physician's orders
Resident was not accorded dignity

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tobola conducted a visit to deliver complaint investigation findings and met with Administrator Siobhan Lehman. LPA toured the facility, reviewed facility files and interviewed staff and outside parties.

The complaint alleges staff did not follow physician's orders regarding medication administration. Based on a review of resident R1's Centrally Stored Medication Records LPA found that R1 was prescribed a laxative medication to be administered daily for stool softening as of December 2020. However, LPA confirmed that R1's Physician had sent a discontinuation order for the prescribed laxative to be changed to a PRN on 2/19/2021. LPA found that the discontinue order was not carried out by staff and the laxative was administered to R1 on 2/20/2021 against Physician's orders. Based on facility not following Physician's medication orders for R1 the allegation is SUBSTANTIATED.

Continue onto LIC9099-C

Substantiated

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: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/19/2021 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 21-AS-20210219144353

FACILITY NAME:	PARAMOUNT HOUSE SENIOR LIVING		FACILITY NUMBER:	486803710
ADMINISTRATOR:	SIOBHAN LEHMAN		FACILITY TYPE:	740
ADDRESS:	2061 PEABODY RD		TELEPHONE:	(707) 455-0300
CITY:	VACAVILLE	STATE: CA	ZIP CODE:	95687
CAPACITY:	95	CENSUS: 78	DATE:	06/03/2021
		UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Siobhan Lehman, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not ensure changes in resident's condition were reported to a physician in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tobola conducted a visit to deliver complaint investigation findings and met with Administrator Siobhan Lehman. LPA toured the facility, reviewed facility files and interviewed staff and outside parties.

Complaint alleges staff did not ensure changes in resident's condition were being reported to a physician in a timely manner. Based on interviews with staff and outside parties and a review of faciltiy records LPA found that the facility records Narrative Charts for any resident changes of condition. LPA reviewed R1's Narrative Chart and found that the facility staff notify R1's responsible party and Physician of R1's changes of condition. However, due to conflicting information and statements received the allegation is found to be UNSUBSTANTIATED.

A finding that the complaint allegations staff did not ensure changes in resident's condition were reported to a physician in a timely manner is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Appeal Rights Given.

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: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20210219144353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING	FACILITY NUMBER: 486803710
	VISIT DATE: 06/03/2021

NARRATIVE

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Complaint alleges resident was not accorded dignity regarding continence care products not being changed in a timely manner. Based on interviews with staff, outside parties and residents LPA found that resident R1 has been left in soiled continence care products on several occasions. R1 requested for staff to change their soiled continence care products but was not changed for several hours. Based on staff leaving R1 in soiled continence care products on several occasions without changing R1 in a timely manner, the allegation is SUBSTANTIATED.

A finding that the staff did not follow physician's orders and resident was not accorded dignity regarding continence care products not being changed in a timely manner are substantiated meaning that the allegations are valid because the preponderance of the evidence standard has been met.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210219144353

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARAMOUNT HOUSE SENIOR LIVING	FACILITY NUMBER: 486803710
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/04/2021 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	87625(b)(3) Managed Incontinence. Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement was not met as eveidence by:***	1 2 3 4 5 6 7	Facility failed to ensure residents with continence care are properly managed. Administrator to ensure that residents who are accepted and/or retained that have incontinence needs will have their needs met and will have an incontinent care plan documented and in place so that facility staff can ensure meeting residents'
	8 9 10 11 12 13 14	Based on interviews with staff and residents LPA found that resident R1 had been left in soiled continence care product for hours after R1 had contacted staff for assistance. This poses as an immediate health and safety risk to resident in care.	8 9 10 11 12 13 14	incontinent care needs. Licensee to submit facility's policy and procedures regarding incontinent care-managed incontinence along with a written plan of future compliance regarding this regulation and how they will ensure all shifts are following the plan. Procedures and plan to be submitted to CCL by POC due date of 6/5/2021
Type B 06/15/2021 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	87465(c)(2) Indicental Medical & Dental Care. Once ordered by the physician the medication is given according to the physician's directions. This requierment was not met as evidence by:***	1 2 3 4 5 6 7	Facility failed to ensure resident's medication orders were followed according to physician's directions. Administrator agrees to review regulation 87465 with LVN and medtech staff to ensure residents' medical & dental care needs are met. Administrator to submit Proof of Corrections LIC9098 to CCL by POC due date of 6/15/2021.
	8 9 10 11 12 13 14	Based on interviews wth staff and review of facility records LPA found that R1's Physician had sent a discontinue order for R1's laxative prescription to be changed to a PRN. S1 was found to have continued administering R1 the laxative medication daily and against Physician's orders.	8 9 10 11 12 13 14

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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021

LIC9099 (FAS) - (06/04)

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