425802104-12-31-2021-29-AS-KBUY-CA8PUY-20211231103816

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802104
Report Date: 12/30/2021
Date Signed: 12/31/2021 09:41:04 AM

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
04/29/2020 and conducted by Evaluator Arien Diaz

COMPLAINT CONTROL NUMBER: 29-AS-20200429102908

FACILITY NAME:	FOUNTAIN SQUARE OF LOMPOC		FACILITY NUMBER:	425802104
ADMINISTRATOR:	KENNY ESPINAL		FACILITY TYPE:	740
ADDRESS:	1420 W. NORTH AVE		TELEPHONE:	(805) 736-1234
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	130	CENSUS:	DATE:	12/30/2021
		UNANNOUNCED	TIME BEGAN:	12:27 PM
MET WITH:	Robin Murray Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Resident's medication is not being recorded.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz.

On the allegation: Resident's medication is not being recorded. All staff stated that there is strong communication among the MedTech’s. 4 out of 4 MedTech’s stated all medications are always distributed, documented, and signed off by the MedTech’s. The MedTech’s also document if residents refuse their medication. Most residents use the bubble pack and therefore simple to verify if medications have not been administered and recorded. The MedTech’s review the electronic mar and communicate with the MedTech on the prior shift. According to the staff, MedTech’s would be aware if medications were not administered and recorded because the Mar is reviewed daily. The staff are also made aware if medications are not administered because the electronic mar will highlight residents that have not received their mediation yet.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

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

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20200429102908

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: 12/30/2021

NARRATIVE

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4 out of 4 MedTech’s stated there are no issues recording medications at the facility. 2 out of 9 residents stated they are not familiar with the medication recording process. 7 out 9 residents stated that MedTech’s follow a schedule to administer prescribed medication at the prescribed time. The residents stated that the MedTech’s are well trained and keep an accurate log of the medication that is given. The residents stated that the MedTech’s are dependable and do their job well. On 9/12/21 LPA reviewed the MAR and Centrally stored medication log for Resident #2 (R2). LPA observed that prescribed medications were given as prescribed and recorded in the MAR. LPA noted that in April 2020, an over the counter eyedrop was logged on the Centrally stored medication log because R2’s family brought it to the facility. However, it did not have a start date on the Centrally stored log and was not listed on the MAR because R2 did not have a physician’s order for it. Based on observations and data collected from interviews, the allegation: Resident's medication is not being recorded is deemed unsubstantiated at this time.

Exit interview conducted, and a copy of this report issued.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

LIC9099 (FAS) - (06/04)

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