486803710-6-23-2021-21-AS-KMOA-C56THS-20210722144510

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803710
Report Date: 06/23/2021
Date Signed: 06/23/2021 06:36:53 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: 76	DATE:	06/23/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Richie Rimigio, Acting Administrator		TIME COMPLETED:	09:20 AM

ALLEGATION(S):

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Staff did not provide assistance in meeting resident's need for medical appointment with physician

INVESTIGATION FINDINGS:

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On 6/23/2021 Licensing Program Analyst (LPA) Tobola conducted a complaint investigation for the purpose of delivering the complaint findings and was met by Acting Administrator Richie Remigio. LPA conducted a tour of the facility, interviews with staff, residents and outside parties and reviewed facility files.

Complaint alleges staff did not provide assistance in meeting resident's need for medical appointment with physician due to facility staff (S1) not attending. Based on facility record review and interviews with staff and outside parties LPA found that the facility did not have any record of R1's scheduled appointment with R1's physician in February of 2021. Upon further review LPA was unable to find any documentation of the facility rescheduling R1's missed medical appointment.

Continued 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: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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-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: 06/23/2021

NARRATIVE

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In addition, LPA conducted an interview with R1's healthcare provider and LPA found that R1's video appointment with the healthcare provider was unsuccessful due a "no show" from RCFE facility staff S1, meaning the allegation, staff did not provide assistance in meeting resident's need for medical appointment with physician is found to be SUBSTANTIATED.

The preponderance of evidence standard has been met, therefore the above allegation, staff did not provide assistance in meeting resident's need for medical appointment with physician is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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: 06/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2021 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465(a)(1) INCIDENTAL MEDICAL & DENTAL CARE. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidence by:***	1 2 3 4 5 6 7	The Licensee failed to ensure the arranging or assisitng in arranging for medical and dental care appropriate to the condition and needs of resident. The Administrator agrees to review regulation 87465 and submit Proof of Corrections (LIC9098) to CCL by 6/28/2021.
	8 9 10 11 12 13 14	Based on interviews with R1's Healthcare Provider P1, LPA found that facility staff (S1) failed to successfully conduct a scheduled medical video appointment for R1. In addition, the facility was unable to provide documentation of the scheduled video visit for R1 and a rescheduling to ensure R1 was assisted with arranging for R1's medical care.	8 9 10 11 12 13 14
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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 Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC9099 (FAS) - (06/04)

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