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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802104
Report Date: 04/12/2024
Date Signed: 04/12/2024 03:25:34 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
11/16/2023 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20231116091548
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:0CENSUS: 62DATE:
04/12/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sarah Kau, Community Relations DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff do not clean resident’s soiled furniture
Staff do not safeguard resident’s personal belongings
Staff do not meet resident's dental hygiene needs
INVESTIGATION FINDINGS:
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On 04/12/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to the facility above to issue final findings. LPA arrived at the facility, met with Community Relations Director Sarah Kau as the Administrator was not present, and announced the purpose of the visit.

On the allegation: Staff do not clean resident’s soiled furniture. It is alleged that Resident #1 (R1’s) chair is saturated with urine, and staff have continued to place R1 in the wet chair. The allegation states that the Administrator of the facility was notified regarding the status of the urine-soaked chair a week before the complaint was filed on 11/16/2023 and the Administrator allegedly stated that the chair would be cleaned and that R1 would not be placed in the urine-soaked chair. According to the allegation, one day prior to the complaint being filed, the Administrator was spoken to again and the chair had not been cleaned.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
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 8
Control Number 29-AS-20231116091548
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: 04/12/2024
NARRATIVE
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On 11/16/2023, Licensing Program Analyst (LPA) Brian Phillips conducted an initial 10-day complaint investigation visit to the facility above. During this visit, LPA conducted Staff member interviews. LPA interviewed Staff member #1 (S1) about the allegation that R1’s chair being saturated with urine, and that staff have placed R1 in the wet chair. S1 stated that the facility uses upholstery furniture cleaning equipment to clean all the furniture in the facility including resident furniture in resident rooms. However, the industrial piece of equipment that was used to clean facility furniture and upholstery had broken, and there was no machine/equipment to clean the furniture for over a week. LPA asked if a resident had an accident in their room what would be the cleaning process while the machine/equipment for upholstery was broken and S1 stated that Staff would most likely have to clean the furniture by hand if it was noticed. Additional interviews by LPA with multiple Staff members regarding this allegation corroborated the statements made by S1. All Staff members interviewed by LPA stated that the facility was unable to clean the chair due to not having working furniture/upholstery cleaning equipment during the period alleged in the complaint. S1 denied that any resident would intentionally be placed in a chair that was soiled or wet or smelled strongly of urine, but that R1’s furniture was unable to be cleaned for a period of time.

Based on the information obtained, there was Sufficient evidence to prove the allegation. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Staff do not safeguard resident’s personal belongings. It is alleged that R1 was provided a new pack of washable, waterproof, large heavy-duty pads to be used over R1’s personal furniture, to cover the entire surface area of the furniture. R1’s name was written on the box, and they were meant to last for some time, but the box has disappeared along with R1’s personal toothbrush.

According to LPA interviews, the facility was notified of the missing personal property one (1) week prior to the complaint being filed on 11/16/2023, and Staff members stated that none of the staff knew where the box of pads was, but that they are going to look for it. At the time the complaint was filed, the box of pads was never located. R1’s personal toothbrush also went missing along with the box of pads but was able to be located although it was moldy and had pieces of soap attached. On 11/16/2023, LPA interviewed S1 about the allegation that R1 was provided a new pack of washable, waterproof, large heavy-duty pads to be used over R1’s personal furniture, to cover the entire surface area of the furniture so that R1’s furniture would not be dampened by urine. S1 stated that the facility uses upholstery furniture cleaning equipment to clean all the furniture in the facility including resident furniture in resident rooms.

Continued on 9099-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20231116091548
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: 04/12/2024
NARRATIVE
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However, the industrial piece of equipment that was used to clean facility furniture and upholstery had broken, and there was no machine/equipment to clean the furniture for over a week. LPA asked if a resident had an accident in their room what would be the cleaning process while the machine/equipment for upholstery was broken and S1 stated that Staff would most likely have to clean the furniture by hand if it was noticed. S1 did not think that any resident room smelled strongly of urine unless a resident had just had an accident and staff did not yet have time to clean up after the resident. LPA asked about materials being brought by relatives for residents to help with hygiene and S1 stated that sometimes the Staff misplace hygiene products brought by family members, but that Staff members always look for anything misplaced to find it as quickly as possible. No Staff member stated to LPA during any interview that the box of pads had been located or used on R1’s furniture. Due to the lack of the facility to safeguard or use the personal waterproof pads provided for R1, R1’s furniture had been soiled with urine. Due to the lack of the facility to safeguard the personal toothbrush of R1, it was lost and had mold with pieces of soap attached when found.

Based on the information obtained, there was Sufficient evidence to prove the allegation. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Staff do not meet resident's dental hygiene needs. It is alleged that Staff are not assisting R1 with brushing their teeth. R1 hasn’t had their teeth brushed for some time as their toothbrush also went missing along with the box of pads, and when the toothbrush reappeared it had mold and a piece of soap in it.

The Preplacement Appraisal Information for R1, dated 02/20/2017, indicates that R1 needs Services and help with bathing, hair care, and personal hygiene. Appraisal Information for R1, dated 08/29/2017, also indicates that R1 needs Services and help with bathing, hair care, and personal hygiene. A Physician’s Report for Residential Care Facilities For the Elderly (RCFE) date 02/04/2019 documented that R1 does not wear dentures and that R1 has the capacity for self-care, being able to dress/groom self and able to feed self. The Resident Assessment for R1 dated 07/07/2021 and signed 07/08/2021 documented that R1 was Independent with no Care Level needed in the care categories of Grooming and Meals. The resident assessment states that R1 can ambulate, and the only risks are fall concerns, psychosocial care, and assistance bathing. The facility Needs and Services Plan (ANS) for R1 dated 07/01/2021 documented that R1 will have Staff assistance with grooming as needed and Staff will encourage R1 to participate in self-grooming as appropriate. Continued on 9099-C

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20231116091548
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: 04/12/2024
NARRATIVE
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A Physician’s Report for R1 signed and dated 02/18/2022 documented that R1 was not at risk if allowed direct access to personal hygiene items such as a toothbrush. This same Physician’s Report stated that R1 was unable to groom themselves and did not have the capacity for self-care aside from being able to feed themselves. A Physician Resident Assessment for R1 completed in 2022 indicated that regarding Personal Hygiene; R1 has their own teeth, R1 requires assistance with grooming (deodorant, comb/brush hair), R1 requires assistance with nail care, and R1 does not have any issues with their teeth (capped, broken, missing, loose). R1 had Physician Contacts on 07/13/2023, 09/05/2023, and 10/09/2023 for episodes of vomiting which required the management/modification of R1’s medications. On 11/01/2023, a Physician Visit Form documented that R1 had an appointment to be examined due to disputing the information on their Physicians health history documentation. The Physician Visit Form indicated that the examination could not be completed due to the very poor oral hygiene of R1, which prevented a visual examination.

Based on the information obtained, there was Sufficient evidence to prove the allegation. Therefore, the allegation is deemed Substantiated at this time.

Exit interview conducted, a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
11/16/2023 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20231116091548

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:0CENSUS: 62DATE:
04/12/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Sarah Kau, Community Relations DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident’s room is malodorous
INVESTIGATION FINDINGS:
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On 04/12/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced subsequent complaint visit to the facility above to issue final findings. LPA arrived at the facility, met with Community Relations Director Sarah Kau as the Administrator was not present, and announced the purpose of the visit.

On the allegation: Resident’s room is malodorous. It is alleged that R1’s room smells strongly of urine. The allegation states that the odor of urine has remained in R1’s room for multiple weeks.

On 11/16/2023, Licensing Program Analyst (LPA) Brian Phillips conducted an initial 10-day complaint investigation visit to the facility above. During this visit, LPA conducted both Staff member and resident interviews. No individual interviewed by the LPA indicated that any resident’s bedroom had a strong smell of urine. LPA personally observed the room belonging to R1 and did not smell a strong odor of urine.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 29-AS-20231116091548
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: 04/12/2024
NARRATIVE
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 LPA physically observed other resident bedrooms in the memory unit of the facility and did not observe any strong odors of urine in any resident bedroom or in any common area of the facility. In addition to the visit to the facility by the LPA on 11/16/2023, LPA has also personally physically visited and observed the facility on 5/25/2023, 8/31/2023, 10/4/2023, 10/31/2023, 11/14/2023, 11/28/2023, and 04/12/2024. During no visit did LPA ever personally observe the strong odor of urine in any of the common areas of the facility or resident bedrooms visited. During multiple visits by the LPA, it appeared to the LPA that the facility was in the process of cleaning areas including the dining room, bathrooms, hallway areas, and resident bedrooms. On 11/16/2023, LPA conducted interviews with multiple Staff members about R1’s chair being saturated with urine and R1’s room smelling strongly of urine. S1 stated that the facility uses upholstery furniture cleaning equipment to clean all the furniture in the facility including resident furniture in resident rooms. However, the industrial piece of equipment that was used to clean facility furniture and upholstery had broken, and there was no machine/equipment to clean the furniture for over a week. LPA asked if a resident had an accident in their room what would be the cleaning process while the machine/equipment for upholstery was broken and S1 stated that Staff would most likely have to clean the furniture by hand if it was noticed. S1 did not think that any resident room smelled strongly of urine unless a resident had just had an accident and staff did not yet have time to clean up after the resident. No Staff member or resident interviewed indicated that R1’s room had a malodorous odor smelling strongly of urine.

Based on the information obtained, there was Insufficient evidence to prove the allegation. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, a copy of this report was provided to the facility.

SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 29-AS-20231116091548
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: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2024
Section Cited
CCR
87468.1(a)(2)
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Section 87468.1(a)(2) Personal Rights. (a) Residents in all RCFEs shall have the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment
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The Licensee will provide evidence of a scheduled training for all Staff members on the personal rights of residents in care. The facility will repair or replace any machine or tool used for the cleanliness and hygiene of residents in care as soon as possible.
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This requirement was not met based on interviews and record review; licensee did not comply with section cited above when Staff failed to clean resident’s soiled furniture which posed an immediate health and safety risk to residents in care.
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Type A
04/15/2024
Section Cited
CCR
87468.1(a)(12)
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Section 87468.1(a)(12) Personal Rights. (a) Residents in all RCFEs shall have the following personal rights: (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money.
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The Licensee will provide evidence of a scheduled training for all Staff members on the personal rights of residents in care. The facility will take appropriate measures to safeguard the personal belongings of residents in care.
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This requirement was not met based on interviews and record review; licensee did not comply with section cited above when Staff failed to safeguard the personal belongings of resident which posed an immediate health and safety risk to residents in care.
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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: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20231116091548
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: 04/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/15/2024
Section Cited
CCR
87464(f)(1)
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Section 87464(f)(1) Basic Services. (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). Facility responsibility for assistance with…personal care.
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Licensee agrees to provide evidence of a scheduled training on Health Related Services for residents in care required for all Staff members of the facility. The facility will take appropriate measures to ensure needed services are provided to residents in care.
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This requirement was not met based on interviews and record review; licensee did not comply with section cited above when Staff failed to assist resident with brushing teeth which posed an immediate health and safety risk to residents in care.
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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: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8