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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802104
Report Date: 09/23/2020
Date Signed: 10/08/2020 05:20:09 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:FOUNTAIN SQUARE OF LOMPOCFACILITY NUMBER:
425802104
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:1420 W. NORTH AVETELEPHONE:
(805) 736-1234
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:130CENSUS: DATE:
09/23/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kenny EspinalTIME COMPLETED:
11:20 AM
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Licensing Program Analyst (LPA) Arien Diaz conducted a case management visit to the facility above. Due to the situation surrounding the Coronavirus Disease 2019 (Covid-19) and the implementation of mitigation measures, today’s visit was conducted by telephonic video with the Administrator Kenny Espinal.

The above facility reported to Community Care Licensing Resident 1 (R1) died on September 16, 2020 of apparent suicide at the facility.

LPA requested R1’s current physicians report, admission agreement, current service plan, current medication logs, internal notes. A current staff roster, resident roster, and staff contact information were also requested.

CCL has referred the case to the department’s Investigation Branch (IB) for further investigation.



Exit interview conducted and hard copy of report provided via email to the Administrator for signature. Administrator will mail signed hard copy of report to LPA at CCL’s Goleta office.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2020
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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