<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802104
Report Date: 09/23/2022
Date Signed: 09/23/2022 04:20:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20211028161558
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: 63DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robin Murray, Administrator and Jessica Ramirez, Memory Care DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility kitchen is unsanitary
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegation. LPA met with Administrator Robin Murray and Jessica Ramirez, Memory Care Director and explained the reason for the visit.

The investigation was started on 10/29/2021 by LPA Chavez. LPA interviewed staff and requested relevant documents on 10/29/2021. LPA Olson conducted a subsequent visit to the facility on 09/21/2022 to continue the investigation. LPA Olson requested documents, interviewed staff, residents, and administrator on 09/21/2022.

On the allegation: Facility kitchen is unsanitary. On 10/29/2021, LPA Chavez toured the kitchen with Administrator and observed the kitchen floor to be dirty and sticky. Administrator confirmed the staff sweep and mop the kitchen once per day in the evening. Administrator stated they would deep clean the floor. Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 7
Control Number 29-AS-20211028161558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LOMPOC
FACILITY NUMBER: 425802104
VISIT DATE: 09/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Administrator provided documentation showing the kitchen received a pressure wash steam cleaning to remove grease on 6/1/2021, and 9/28/2021. On 09/09/2022, LPA Olson and Cortez toured the facility and observed the floor was dirty. LPA Olson also obtained a general cleaning schedule for the kitchen, which indicated the floor should be cleaned daily. On 09/21/2022, LPA toured the kitchen again and observed the kitchen floor to be dirty and sticky. Administrator stated they would review the cleaning schedule and add additional floor cleaning to ensure the kitchen stays clean. Based on the information obtained, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

Exit interview, report, 9099-D, and appeal rights were emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20211028161558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LOMPOC
FACILITY NUMBER: 425802104
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
87303(a)(1)
1
2
3
4
5
6
7
87303(a)(1) Maintenance and Operation. Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The kitchen floor was immediately cleaned. Administrator agreed to revise the cleaning schedule and ensure it is followed. Administrator will send a new schedule to CCL by 9/30/2022.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the above cited section when the kitchen floor was dirty, which posed a potential health risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2021 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20211028161558

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: DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robin Murray, Administrator and Jessica Ramirez, Memory Care DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to neglect, resident sustained serious injury while in care
Staff did not seek timely medical care for resident
Staff provides care and supervision while intoxicated
Due to lack of supervision, residents sustained multiple falls while in care.
Staff are not meeting residents showering needs
Staff did not properly assist residents with their medications
Staff did not provide a call button to resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Robin Murray and Jessica Ramirez, Memory Care Director and explained the reason for the visit.

The investigation was started on 10/29/2021 by LPA Chavez. LPA interviewed staff and requested relevant documents on 10/29/2021. LPA Olson conducted a subsequent visit to the facility on 9/21/2022 to continue the investigation. LPA resquested documents, interviewed staff, residents, and administrator on 9/21/2022.

On the allegations: Due to neglect, resident sustained serious injury while in care; Staff did not seek timely medical care for resident; Staff provides care and supervision while intoxicated. The investigation into these allegations was conducted by Investigations Branch (IB) Investigator Kujawa. Kujawa interviewed administrator on 1/14/2022 at 5:35pm; interviewed staff on 2/14/22, 3/22/2022 and 3/29/2022; and interviewed residents on 3/22/2022. Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20211028161558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LOMPOC
FACILITY NUMBER: 425802104
VISIT DATE: 09/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
It was alleged that due to staff neglect, R1 and R2 both sustained serious injuries while in care. According to interviews and R1’s physician’s report and appraisal, R1 walked on their own about the facility without staff assistance. R1 used a walker. Staff described R1 as a “very good walker.” Staff also stated R1 was an extremely good walker and did not require any assistance from staff when walking. R1 sustained an unwitnessed fall on 10/8/2021 and was found around 9:15am. R1’s neighbor alerted staff about the fall and staff responded to R1. R1 was observed to have swelling on the forehead and complained of pain in their neck and abdomen. Staff did not move the resident due to the complaint of neck pain and called 9-1-1. R1 was sent to a local hospital, but was then transferred to a larger hospital for admission. R1 was diagnosed with fractures of the neck and ribs. Staff interviewed stated they did not believe R1’s falls were sustained as a result of neglect or lack of supervision.

On 9/30/2021, R2 had an unwitnessed fall and sustained facial bruising. On 10/19/2021 at 2:00am, R2 sustained another unwitnessed fall. Staff found R2 on the floor next to their bed. Staff and med tech observed that R2 did not appear to be in pain, did not express pain, and did not have any apparent injuries. Med tech also stated R2 slept through the rest of the night. Hospice came in the morning to assess R2 and observed bruising on their side near their ribs. Hospice nurse advised the staff to monitor R2 and provide Tylenol as needed. Later in the day around 3:30pm, R2’s family visited R2 and wanted R2 assessed at a hospital after discussion with Hospice and the administrator. R2’s family advised they would transport R2 to the hospital, but the administrator called 9-1-1 instead for transport. R2 was diagnosed with fractured ribs and a minor prolapsed lung. R2’s family declined hospitalization for R2 and the resident returned to the community on hospice.

It was alleged that Staff 1 (S1) was intoxicated while on shift and did not seek timely medical attention for R2. The reporting party later stated it was just a rumor that S1 was intoxicated, and had not observed S1 intoxicated. Interviews conducted with facility staff showed the facility acted in a timely manner. R2 was immediately attended to and examined by S1. S1 observed R2 and found no signs of pain or injury, and hospice provided medical attention to R2. Administrator stated she was not aware of S1 ever having been intoxicated while at work. Staff interviewed stated they had never seen or heard S1 be intoxicated while at the facility, even when they worked directly with S1, and had only heard rumors. When interviewed, S1 stated they were never intoxicated or hungover while working at the facility, because they would have just called off instead of coming to work.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20211028161558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LOMPOC
FACILITY NUMBER: 425802104
VISIT DATE: 09/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff interviewed stated they did not believe R2’s falls were sustained as a result of neglect or lack of supervision by staff. Based on the information obtained, the allegations are deemed unsubstantiated at this time.

On the allegation: Due to lack of supervision, residents sustained multiple falls while in care.
It was alleged that residents sustained multiple falls in care due to a lack of supervision. LPA Olson interviewed staff, administrator, and reviewed incident reports. LPA determined after incident report review and interviews, that the falls sustained were not as a result of lack of supervision. The facility reviewed each resident with multiple falls to try to determine a root-cause of the falls. The number of falls have significantly decreased in the last year since implementing this procedure. In many of the cases reviewed, the falls were due to resident health issues versus a lack of supervision, as it was determined supervision was not needed for walking. Based on the information obtained, the allegation is deemed unsubstantiated at this time.

On the allegation: Staff are not meeting residents showering needs: LPA interviewed staff, administrator, and residents to investigate this allegation. Residents interviewed in Assisted Living and Memory Care indicated their needs were met and the staff assisted them with showers. Residents indicated they never had to skip showers unless they refused. Staff and administrator also stated residents had not missed showers unless they refused or were not present in the facility. Staff and administrator stated when residents refuse, they try again using various methods to ensure the residents receive their showers. Staff and administrator stated they document resident refusals of showers and follow the shower schedule. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff did not properly assist residents with their medications: Staff interviewed stated on a couple of occasions in 2021, there was only one med tech for both Assisted Living and Memory Care. Staff stated they were able to provide the residents all their bedtime medications by 9pm, after starting around 7pm, but it was difficult to get them all done on time. It was also alleged that a resident was given the wrong night time medication sometime in 2021. Staff and administrator interviewed had no recollection of this happening. The resident named in the complaint could not be found in facility records from that time. LPA requested Medication Administration Records (MARs) for three residents that had similar names, but no medication errors were observed. Based on the information obtained, the allegation is deemed Unsubstantiated at this time. Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7
Control Number 29-AS-20211028161558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LOMPOC
FACILITY NUMBER: 425802104
VISIT DATE: 09/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On the allegation: Staff did not provide a call button to resident: All residents interviewed indicated their needs were met, and staff respond to their call buttons in a timely manner. LPA tested a call button and observed the response time to be 9 minutes. Staff interviewed stated they always respond as quickly as they can to call buttons, and the maximum response time they aim for is 5-10 minutes. LPA reviewed call button logs and observed the response times were mostly less than 10 minutes for the entire month reviewed. Administrator stated management routinely reviews the call button response time log to ensure response times are appropriate, and to looks for trends. Administrator stated they had observed very long response times on occasion, but through investigation it was discovered this happened when residents took their pendants out of the facility and pressed it. In these cases, staff were not able to clear the pendant until the resident physically returned to the facility. Administrator stated they instructed staff who are actively assisting residents in care to only leave the resident being assisted and respond to the call button if it is safe to do so. Administrator stated if the resident being cared for cannot be left alone, the staff should wait to respond to the other call button or call for other staff to respond. Administrator stated staff were instructed to respond as quickly as possible to residents, but if the resident’s request was not urgent, they could clear the call button and get back to them with the non-urgent item that was needed. Administrator stated they encouraged residents to push the call button again if staff did not respond with the non-urgent need within 5-10 minutes. Based on the information obtained, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, a copy of the report was emailed to Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7