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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802104
Report Date: 12/30/2021
Date Signed: 12/30/2021 07:59:15 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
08/03/2020 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20200803103025
FACILITY NAME:FOUNTAIN SQUARE OF LOMPOCFACILITY NUMBER:
425802104
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:1420 W. NORTH AVETELEPHONE:
(805) 736-1234
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:130CENSUS: 60DATE:
12/30/2021
UNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Robin MurrayTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Inadequate staffing to meet the residents' needs.
Staff not able to assist with toileting.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Diaz conducted a subsequent complaint visit to deliver final findings of the complaint investigation. LPA met with Robin Murray and explained the purpose of the visit.

LPA Diaz reviewed facility documents and conducted interviews with staff, residents and a resident family member. LPA interviewed staff on 8/12/2020 at 10:48am; on 06/26/2021 at 11:56am and 4:52pm; on 06/27/2021 at 4:35pm, 5:26pm, 6:11pm, and 6:30pm; on 6/29/2021 at 1:50pm; and on 06/30/2021 at 6:30pm. LPA interviewed residents on 06/28/2021 at 3:20pm, 3:32pm, 3:52pm, and 4:43pm; and on 07/04/2021 11:30am, 11:47am, 12:11pm, 4:00pm, and 4:17pm. LPA interviewed family member on 07/04/2021 on 3:30pm.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (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)
Page: 1 of 5
Control Number 29-AS-20200803103025
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 the allegation: Inadequate staffing to meet the residents' needs. All staff stated that the overnight shift consists of occasionally 5, but often 3 staff members to provide care for 67 residents. The facility has a memory care unit and an assisted living unit. During 3-person shift, the staff members consists of 2 caregivers and 1 MedTech, thus 1 caregiver for memory care and 1 caregiver for assisted living. Incontinent residents primarily in memory care were found wet and their mattress was found soaked. 1 out of 9 staff stated its challenging for 2 caregivers to cover the overnight shift, and residents were found wet in the morning. 5 out of 9 staff they have experienced staffing challenges due to caregivers calling out absent for evening shifts. 2 out of 9 staff stated, the lack of staffing can delay residents from receiving showers. 9 out of 9 staff stated that the caregivers can respond in 5-10 minutes but sometimes respond in 20-30 minutes if caregivers are helping other residents. 4 out of 9 staff stated that there is not enough backup staffing for support, and to ensure that all shifts have coverage. 2 out of 9 staff stated there are staffing issues when providing care to the residents and fulfilling the resident’s needs. According to the administrator, internal backup staffing is readily available, and the facilities can use two staffing agencies and nurse core for back up staffing. 2 out of 9 residents stated there is a short wait time, but this is not common. The residents also stated that the if the facility is short staffed, then residents may wait up to 15-20 minutes. Based on the evidence gathered through interviews and records reviewed, the allegation Inadequate staffing to meet the residents' needs. is deemed substantiated at this time.

On the allegation: Staff not able to assist with toileting. 1 out of 9 staff stated, 2020 was a bad year regarding wet residents. The staff stated, the nocturnal shift consists of a minimum of 3 staff members. Incontinent residents primarily in memory care were found wet and their mattress was found soaked. 1 out of 9 staff stated its challenging for 2 caregivers to cover the overnight shift, and residents were found wet in the morning. 7 out of 9 staff stated the overnight crew is good at competing their rounds and some accidents happen, and briefs are wet, but residents are not soaked or left for long periods of time. 2 out of 9 residents stated that it would be nice if the staff arrived sooner. The residents also stated that the if the facility is short staffed, then residents may wait up to 15-20 minutes Based on the evidence gathered through interviews and records reviewed, the allegation Staff not able to assist with toileting is deemed substantiated at this time.

Exit interview conducted, and a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (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)
Page: 2 of 5
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
08/03/2020 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20200803103025

FACILITY NAME:FOUNTAIN SQUARE OF LOMPOCFACILITY NUMBER:
425802104
ADMINISTRATOR:KENNY ESPINALFACILITY TYPE:
740
ADDRESS:1420 W. NORTH AVETELEPHONE:
(805) 736-1234
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:130CENSUS: 60DATE:
12/30/2021
UNANNOUNCEDTIME BEGAN:
01:51 PM
MET WITH:Robin MurrayTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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2
3
4
5
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8
9
Staff not treating resident with dignity.
INVESTIGATION FINDINGS:
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On the LPA Diaz reviewed facility documents and conducted interviews with staff, residents and a resident family member. LPA interviewed staff on 8/12/2020 at 10:48am; on 06/26/2021 at 11:56am and 4:52pm; on 06/27/2021 at 4:35pm, 5:26pm, 6:11pm, and 6:30pm; on 6/29/2021 at 1:50pm; and on 06/30/2021 at 6:30pm. LPA interviewed residents on 06/28/2021 at 3:20pm, 3:32pm, 3:52pm, and 4:43pm; and on 07/04/2021 11:30am, 11:47am, 12:11pm, 4:00pm, and 4:17pm. LPA interviewed family member on 07/04/2021 on 3:30pm.

On the allegation: Staff not treating resident with dignity. All staff stated that the residents are treated well and treated with dignity. The staff provide residents with privacy and respect and will immediately tell the nurses and document any concerns regarding the residents. According to the staff, caregivers are patient and kind towards the residents and never discourteous. Staff stated they are mandated reporters and would report any abusive behavior, and the caregivers aim to satisfy the residents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (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)
Page: 3 of 5
Control Number 29-AS-20200803103025
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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There is constant communication among staff and residents, and constant communication between staff members to ensure awareness of the resident’s needs. The Administrator stated that the staff does not have a history of being aggressive towards residents. All residents stated they like the caregivers and they treat residents well. All residents stated, the care givers are courteous and respect the privacy of the residents. The caregivers are nice, kind and make the facility comfortable. The Staff treats everyone with dignity, and it is a beautiful place to live, there are no issues at the facility. According to the family member, the staff care about the residents, and the caregivers are all very good. Based On the evidence gathered through interviews, the allegation Staff not treating resident with dignity is deemed usubstantiated at this time.

Exit interview conducted, and a copy of this report issued.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (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)
Page: 4 of 5
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:
FACILITY NUMBER:
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/31/2021
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements – General: Facility personnel shall at all times be.. competent to provide the services necessary to meet resident needs.. facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by:
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The Licensee has agreed to do the following:
1. Submit proof of staff retraining on section 87411(a) to CCLD by 12/31/2021.
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Based on LPAs observations, the Licensee did not comply with the section cited above, as the Licensee failed to ensure Facility personnel is available to provide the services necessary to meet resident needs
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Type B
12/31/2021
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities. Residents shall have all of the following...: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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The Administrator agreed to do the following:
Submit a Plan of Action for residents needs.
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This requirement is not met as evidenced by:
Based on the investigation, the licensee did not comply with the section cited above, and residents were found wet and their mattress was found soaked.
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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: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5