425802104-3-2-2023-29-AS-KBUY-CQDVZT-20230329165317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802104
Report Date: 03/02/2023
Date Signed: 03/02/2023 04:56:43 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
02/21/2023 and conducted by Evaluator Brian Phillips

COMPLAINT CONTROL NUMBER: 29-AS-20230221144846

FACILITY NAME:	FOUNTAIN SQUARE OF LOMPOC		FACILITY NUMBER:	425802104
ADMINISTRATOR:	ROBIN MURRAY		FACILITY TYPE:	740
ADDRESS:	1420 W. NORTH AVE		TELEPHONE:	(805) 736-1234
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	130	CENSUS: 61	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Robin Murray, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not dress resident appropriately

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Brian Phillips and Rachael De Leon conducted a 10-day complaint visit to the facility above on 03/02/2023 at 10:15am. LPAs met with Administrator Robin Murray and explained the purpose for the visit.

LPA's requested the following records: Staff roster w/telephone numbers, February Staff Schedule, Resident Roster, Random selection of MC residents, Appraisal Needs and Services plan (ANS), 8 MC Residents ID and Emergency Contact sheets, Staff notes for February 2023, Incident reports with Residents verbal or physical confrontations.

LPA Phillips interviewed Residents on 03/02/2023 at 12:15pm, 12:30pm, 1:35pm, 2:15pm and 2:30pm. LPA Phillips interviewed witness at 1:00pm on 03/02/2023. LPA De Leon conducted interviews with staff on 03/02/2023 at 12:31 pm, 1:50pm, 2:00pm, 2:13pm, 2:22pm, 2:40pm. LPA De Leon intrviewed witness on 03/02/2023 at 8:39am. Cotinued 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

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 5

Control Number 29-AS-20230221144846

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC	FACILITY NUMBER: 425802104
	VISIT DATE: 03/02/2023

NARRATIVE

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On the allegation: Staff did not dress resident appropriately. LPA's interviewed staff and witnesses that revealed that some residents are found in the same clothing the next day, some residents have pajamas and some do not, and some are left in briefs with a T-shirt over night. Based on the evidence this allegation is deemed Substantiated at this time.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
02/21/2023 and conducted by Evaluator Brian Phillips

COMPLAINT CONTROL NUMBER: 29-AS-20230221144846

FACILITY NAME:	FOUNTAIN SQUARE OF LOMPOC		FACILITY NUMBER:	425802104
ADMINISTRATOR:	ROBIN MURRAY		FACILITY TYPE:	740
ADDRESS:	1420 W. NORTH AVE		TELEPHONE:	(805) 736-1234
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	130	CENSUS: 61	DATE:	03/02/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Robin Murray, Administrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff are not cleaning resident's teeth
Due to lack of supervision, residents are engaging in physical altercations with other residents

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 29-AS-20230221144846

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC	FACILITY NUMBER: 425802104
	VISIT DATE: 03/02/2023

NARRATIVE

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On the allegation: Staff are not cleaning residents teeth. LPA's conducted interviews with staff and residents which revealed some residents are independent and do not get help from staff to brush teeth, some residents are combative and do not allow the staff to brush their teeth. Staff stated Medication Technicians (Med-Tech) are the only staff that take care of dentures nightly and are the only ones that can help residents with dentures. Based on the lack of evidence the allegation is deemed Unsubstantiated at this time.

On the allegation: Due to lack of supervision, residents are engaging on physical altercations with other residents. LPA's Phillips and De Leon conducted interviews with staff and residents which revealed that
even when staffing is full or short altercations with residents continue to happen regardless of staff supervision. Staff interviews revealed 2 residents in the memory care that have verbal and physical altercations and may need a higher level of care. Staff stated it happens often and staff will get in between residents and redirect them. Based on the evidence this allegation is Unsubstantiated at this time.

Exit interview conducted and copy of report printed for Administrator.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 29-AS-20230221144846

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC	FACILITY NUMBER: 425802104
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/02/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/09/2023 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to train staff in resident care with dressing and clothing being appropriate for bed time. Send proof of trianing with all MC staff and signatures to CCL by 03/09/2023.
	8 9 10 11 12 13 14	Based on interviews the licensee did not comply residents were not being changed or dressed appropriately for bed on the PM shift which poses a potential health and safety 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 Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2023

LIC9099 (FAS) - (06/04)

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