425802104-12-30-2021-29-AS-KBUY-CA8PVS-20211231103936

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425802104
Report Date: 12/30/2021
Date Signed: 12/30/2021 07:42:16 PM

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
04/30/2020 and conducted by Evaluator Arien Diaz

COMPLAINT CONTROL NUMBER: 29-AS-20200430090901

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: 60	DATE:	12/30/2021
		UNANNOUNCED	TIME BEGAN:	01:38 PM
MET WITH:	Robin Murray Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Medication was given without physician orders.

INVESTIGATION FINDINGS:

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LPA Diaz reviewed facility documents and conducted interviews with staff and residents. LPA interviewed staff on 12/7/21 between 2:00pm to 4:00pm. LPA interviewed staff on 12/9/21 between 2:00pm to 4:00pm. LPA interviewed staff on 12/10/21 between 10:00am to 5:00pm. LPA interviewed residents on 12/12/21 between 1:00pm and 5:30pm. LPA interviewed residents on 12/13/21 between 2:00pm and 4:00pm.

On the allegation: Medication was given without physician orders. 9 out of 9 staff stated, only prescribed medication is given to the residents, and there no exceptions. 4 out of 4 MedTech’s stated they must have a physician’s orders to administer any medication to a resident. If a MedTech receives an unsigned order, the MedTech must fax the order back to the doctor and ask for a signed medication order. If a medication is not prescribed, then the resident is not allowed to take it. The residents stated they are only given their 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.

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: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

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-20200430090901

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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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 the data collected from interviews, the allegation Medication was given without physician orders is deemed unsubstantiated at this time.

Exit interview, report given.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien Diaz	TELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC9099 (FAS) - (06/04)

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