502700737-6-25-2021-27-AS-SDOB-C5XQFP-20210816120815

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 502700737
Report Date: 06/25/2021
Date Signed: 06/25/2021 03:50:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2021 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20210520121049

FACILITY NAME:	PARAMOUNT COURT SENIOR LIVING		FACILITY NUMBER:	502700737
ADMINISTRATOR:	MONTELLANO, ANTHONY		FACILITY TYPE:	740
ADDRESS:	3791 CROWELL ROAD		TELEPHONE:	(209) 664-9500
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95382
CAPACITY:	100	CENSUS: 71	DATE:	06/25/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Antony Montellano		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Questionable Death.
Staff are not using PPE.
Staff are not reporting Covid-19 cases.

INVESTIGATION FINDINGS:

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On 6/25/2021, Licensing Program Analyst (LPA) Jason Lund arrived at the facility unannounced to complete a complaint investigation regarding the above allegations. LPA Lund meet with Administrator Anthony Montellano and explained the reason for the visit. Current Census 71

LPA Lund reviewed resident (R1) records, facility records interviewed staff and witnesses regarding the above allegations.

Based on the investigation through interviews and records, R1 was referred to hospice on 2/18/2021 and started hospice on 2/21/2021 with a primary diagnosis was Alzheimer’s disease. The hospice certification stated that R1 was terminally ill with a life expectancy of six months or less if the disease follows it normal course. On 5/17/2021 R1 passed away.

Unfounded

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/20/2021 and conducted by Evaluator Jason Lund

COMPLAINT CONTROL NUMBER: 27-AS-20210520121049

FACILITY NAME:	PARAMOUNT COURT SENIOR LIVING		FACILITY NUMBER:	502700737
ADMINISTRATOR:	MONTELLANO, ANTHONY		FACILITY TYPE:	740
ADDRESS:	3791 CROWELL ROAD		TELEPHONE:	(209) 664-9500
CITY:	TURLOCK	STATE: CA	ZIP CODE:	95382
CAPACITY:	100	CENSUS: 71	DATE:	06/25/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator Antony Montellano		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility failed to report incidences.
Staff did not prevent resident from drinking out of a moldy cup.
Staff are not providing services necessary to meet needs of residents.

INVESTIGATION FINDINGS:

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A complaint investigation regarding the above allegations was completed by LPA Jason Lund.

Based on interviews and records review the facility does report to Licensing Unusual Incident/Injury Reports (LIC624) but it unclear if the facility reports all incidents to Licensing.

Based on interviews the facility does bring the food and drinks to the room during the COVID-19 pandemic, but it unclear if the dishes could be left in residents’ room or not.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

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 27-AS-20210520121049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PARAMOUNT COURT SENIOR LIVING	FACILITY NUMBER: 502700737
	VISIT DATE: 06/25/2021

NARRATIVE

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LPA interviewed residents, staff, and reviewed documentation. There are two caregivers, med tecks and management on each shift per memory care and assisted care unit. The information provide does not confirm or deny that residents needs were not met during COVID-19. The facility uses this staffing ratio to meet the needs of the residents for each shift.

Although the allegation may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Administrator Anthony Montellano and a copy of report was left.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 27-AS-20210520121049

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: PARAMOUNT COURT SENIOR LIVING	FACILITY NUMBER: 502700737
	VISIT DATE: 06/25/2021

NARRATIVE

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Through interviews and records review, the facility had sufficient PPE supplies. The facility did lock the supplies with management having access to the supplies. Supplies were always readily available to staff and residents during the COVID-19 epidemic.

Through interviews and records review. The facility did weekly COVID-19 testing on residents and staff and reported positive cases to Licensing and Stanislaus County Public Health, by which the facility was mandated to report to both agencies.

This agency has investigated the complaint allegations. We have found the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4