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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802104
Report Date: 10/08/2021
Date Signed: 10/08/2021 03:54:38 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:ROBIN MURRAYFACILITY TYPE:
740
ADDRESS:1420 W. NORTH AVETELEPHONE:
(805) 736-1234
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:130CENSUS: 65DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Robin Murray, AdministratorTIME COMPLETED:
02:45 PM
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On 10/08/21 at 12:15 PM, Licensing Program Analyst (LPA) Toan Luong contacted Administrator Robin Murray to perform a facility risk assessment. LPA conducted an unannounced on-site One Year Infectious Control Annual visit to the facility. LPA met with Administrator Robin Murray and explained the purpose of the visit.

Administrator took LPA on a physical plant tour of the facility. The facility has submitted a mitigation plan to the department.

The facility is a Residential Care Facility for the Elderly. LPA observed the facility is in good and clean condition. Facility is following Covid-19 guidance. Facility screens all visitors. All staff and visitors were observed wearing masks. LPA recommended administrator have staff fit tested with N95 masks to comply with CAL/OSHA requirements when there is a suspected or confirmed case of Covid-19 among residents.

LPA reviewed the Annual Mitigation Inspection Control Tool Module. Module was addressed with Administrator to satisfaction.

Exit interview was conducted. No deficiencies were cited. Report emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Toan LuongTELEPHONE: (626) 419-1827
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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