<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802104
Report Date: 12/30/2021
Date Signed: 12/30/2021 07:33:33 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
04/29/2020 and conducted by Evaluator Arien Diaz
COMPLAINT CONTROL NUMBER: 29-AS-20200429102908
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:
12:27 PM
MET WITH:Robin MurrayTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect lead to severe hospitalization of resident(s).
Staff did not seek medical attention for resident(s) in a timely manner.
Staff does not treat resident with dignity.

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz.

On the allegations: Resident sustained a compressed spinal fracture at the facility, and Facility failed to seek medical attention in a timely manner. The complaint was referred to Community Care Licensing Investigations Branch and assigned to Investigator Philippe Ryan Miles.

On 05/01/2020, between 1:15 p.m. and 1:45 p.m., Licensing Program Analyst (LPA) Arien Diaz conducted the initial complaint investigation for the above complaint. LPA met with Business Office Manager, Sara Coleman, and requested documents pertinent to the investigation.
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: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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 8
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Investigator Miles conducted interviews with the Administrator, Resident #1 (R1) and caregivers on 06/16/2020 at approximately 5:11 p.m. to 6:38 p.m.; interview with Dr. Reimer on 05/18/2020 at approximately 1:35 p.m., interviews with caregivers on 06/05/2020 at approximately 10:30 a.m. to 1:11 p.m.; interview with caregiver on 06/08/2020 at approximately 10:01 a.m.; interviews with the Administrator, caregivers and med techs on 06/19/2020 at approximately 10:30 a.m. to 2:58 p.m.; and interview with the Responsible Party on 07/07/2020 at approximately 11:33 a.m.

R1 was admitted to the facility July 2019. The Physician Report dated 07/15/2019 indicated R1 had a diagnosis of poor balance, vitamin B-12 deficiency, mild cognitive impairment and occasionally used a walker. The Needs and Services Plan completed by the facility, dated 07/16/2019, stated R1 had a history of falls at home. On 07/30/2019, Dr. Riemer ordered an MRI scan of R1’s brain due to a history of memory loss with vertigo and frequent falling. The conclusion of the MRI scan was a negative exam. On 10/17/2019, R1 was referred by Dr. Riemer to Lompoc Valley Medical Center Speech Therapy due to cognitive dysfunction.

On 04/23/2020, R1 was sent to the Lompoc Valley Medical Center Emergency Room for an unwitnessed fall resulting in R1 sustaining a 20% compressed fracture of the lumber spine at L1. Radiologist, Dr. Enoch, dated the fracture as “about a month old” placing it during R1’s stay at the Fountain Square of Lompoc facility. Dr. Riemer spoke to a friend of R1’s, who indicated R1 had been leaning forward in pain at the facility before the spinal fracture was discovered. Based on medical records reviewed, R1 had difficulty getting out of chairs and complained of lower back pain for the last 4 weeks. In addition, R1 had a history of repeated falls and had been sent to the ER several times based on the repeated falls with generalized weakness.

Based upon the interviews and medical opinions, R1 was not provided the proper level of care and supervision, resulting in repeated unwitnessed falls occurring at the facility. R1 sustained a 20% compressed back fracture that took approximately a month to be diagnosed and treated. Therefore, the allegations above are deemed substantiated.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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: Staff does not treat resident with dignity. 9 out of 9 staff stated they are mandated reporters and would report any abusive behavior. 9 out of 9 staff say they have not witnessed any abuse but would report abuse to the administrator and the licensing agency. The staff provide residents with privacy and dignity. According to the staff, caregivers are patient and kind towards the residents and never discourteous. There is constant communication among staff and residents, and constant communication between staff members to ensure awareness of the resident’s needs. The staff stated that the previous administrator did not interact with the residents often. 3 out of 9 staff stated the previous administrator treated the residents with dignity but did not treat the staff with dignity. 2 out of 9 staff stated some of the caregivers would laugh at the resident with Alzheimer’s and those caregivers were terminated by the previous administrator. Also, the previous administrator was on the phone with a resident and hung up on the resident. The resident stated that the previous administrator was “being a jerk” on the phone. The current Administrator stated that the staff does not have a history of being aggressive towards residents. 1 out of 9 residents stated that previous administrator and a former staff member did not treat them dignity. Resident 3 (R3) stated that they did not see the previous administrator interact with residents often but R3 heard the previous administrator yell at residents in the Hallway. R3 stated that former Staff 1 (S1) would often criticize R3 and criticized the way R3 would tie their shoes. Also, S1 would not give R3 certain foods because R3 was diabetic. 8 out of 9 residents stated they like the caregivers and the residents are treated 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 there are no issues at the facility. According to a family member, the staff care about the residents, and the caregivers are all very good. Based on the evidence gathered through interviews, the allegation Resident's Staff does not treat resident with dignity is deemed substantiated at this time.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 8
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A $500 immediate civil penalty is assessed today for the injury to R1. The licensee was informed that additional civil penalties may be assessed based on Health and Safety Code 1569.49 (f).

Exit interview conducted, civil penalty issued, appeal rights discussed, 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: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2021
Section Cited
HSC
1569.312(a)(e)
1
2
3
4
5
6
7
Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services...to ensure their general health, safety, and well-being. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit plan to provide proper level of care and supervision to ensure residents needs are met. Also Dignity and Change of conidtion Inservice retraiing by 1/5/22
8
9
10
11
12
13
14
Based on interviews and medical opinions, R1 was not provided the proper level of care and supervision, resulting in repeated unwitnessed falls sustaining a 20% compressed spinal fracture, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
12/22/2021
Section Cited
HSC
87465(a)(1)
1
2
3
4
5
6
7
Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan…by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will submit plan on how you will ensure residents receive timely medical attention by 1/5/22
8
9
10
11
12
13
14
Based on medical opinions, R1 sustained a 20% compressed spinal fracture that took approximately a month to be diagnosed and treated, which posed an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
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: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 8
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 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:
12:27 PM
MET WITH:Robin Murray Administrator TIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident's hygiene needs are not being met.
Staff leaves resident's in soiled diaper for an extended period of time.
Staff did not report resident's injury to responsible party.
Staff do not respond to resident's call button in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Diaz conducted a complaint visit to deliver final findings of the complaint investigation conducted by LPA Diaz.

On 05/01/2020, between 1:15 p.m. and 1:45 p.m., Licensing Program Analyst (LPA) Arien Diaz conducted the initial complaint investigation for the above complaint. LPA met with Business Office Manager, Sara Coleman, and requested documents pertinent to the investigation. 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.
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: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 8
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On the allegation: Resident's hygiene needs are not being met. According to the staff, they use a hygiene checklist and document the services given in a log. 8 out of 9 staff stated hygiene services are being given without issues. The residents can refuse services, but the facility will document refusals and follow up. The staff can communicate with the family if they are experiencing difficulties with hygiene services to the residents. The exchange of communication with the family or the doctor is documented. The staff and administrator stated, families are good about bringing hygiene containers for the residents. These containers contain specific hygiene products that the residents like. However, the facility also has extra hygiene products for the residents if needed. The facility has products such as shampoo, bodywash, toothpaste, toothbrush, and dental floss. The caregivers also empty trash cans, dress and toilet residents. The caregivers check off their completed assignments during their daily tasks. There is constant communication among staff and residents, to ensure awareness of the resident’s needs. 9 out of 9 residents confirmed that the facility provides adequate hygiene assistance. The residents are also kept clean and the facility does a good job. The bedrooms, laundry and bed sheets are also clean. According to the complainant, Resident 3 (R3) was ill and R3’s hygiene needs were not met. Based on interviews with R3, R3 is very independent and did not have any issues with services provided by facility staff. LPA reviewed hygiene log for 2020 and verified that the staff provided services to residents to meet their needs. Based on the data collected from interviews, the allegation: Resident's hygiene needs are not being met is deemed unsubstantiated at this time.

On the allegation: Staff leaves resident's in soiled diaper for an extended period of time. 9 out 9 staff stated that residents are not left in soiled diapers or have not heard of residents being left in soiled diapers. 9 out of 9 staff stated that residents are treated with dignity and staff would report to the administrator or the licensing agency if residents were neglected. According to the staff, occasional bed wetting happens, but it is not fair to say that residents are not changed in a reasonable time. Staff stated that residents are frequently checked and changed every 1 or 2 hours and there are no issues with hygiene. All staff stated that hygiene is done well, and the staff members have not seen residents left in soiled diapers. Residents interviewed stated that they are regularly checked by staff and are never left unattended for an extended period. The facility does not allow anyone to be left alone for an extended period and no one is left soiled. All residents confirmed that they are kept clean and monitored by the staff members of the facility. LPA reviewed daily hygiene tasks sheets completed by staff and observed incontinence care was provided to residents. Based on the data collected from interviews, the allegation: Staff leaves resident's in soiled diaper for an extended period of time is deemed unsubstantiated at this time.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Arien DiazTELEPHONE: (747) 230-3890
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 8
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On the allegation: Staff did not report resident's injury to responsible party. 9 out of 9 staff stated that if an injury occurs, then MedTech’s and director would report the injury to the responsible party. The staff would report to the residents Doctor, Power of attorney (POA), conservator, family or emergency contact. The staff would also report to the hospice nurse if applicable. The staff document injuries on incident reports and indicate which parties were contacted. The incidents reports are also filed internally and sent to the licensing agency. 9 out of 9 residents stated that staff regularly communicate with their families, and their families are well informed regarding the status of the residents. The residents also stated that their family members severe as the POA. 6 out of 9 residents experienced an injury in the past and confirmed that the staff responded to their appropriate party. 4 out of 9 residents have not experienced an escalated injury but their families are in contact and well informed by the facility. On 1/17/2020, Resident 4 (R4) went to the Emergency Room. LPA reviewed an incident report submitted by the facility. The incident report indicates R4’s responsible party was contacted via phone, but there was no answer and a message could not be left. On the allegation: Staff did not report resident's injury to responsible party is deemed unsubstantiated at this time.

On the allegation: Staff do not respond to resident's call button in a timely manner. All staff stated they communicate with each other in order to respond to the residents in a timely manner. 9 out of 9 staff stated that caregivers can respond in 5-10 minutes but sometimes respond in 20-30 minutes if caregivers are helping other residents. The caregivers communicate amongst each other to prevent delays and generally respond within minutes. 1 staff member stated that the previous administrator was strict about caregivers responding in 6 minutes. All residents confirmed that the caregivers respond within 10 minutes or less. The residents also stated that the if the facility is short staffed then residents may wait up to 15-20 minutes. On 12/7/21 at 2:56 PM, LPA Diaz had the facility Administrator, arbitrarily press a call button for resident as test. After the call button was pressed, a caregiver responded within 1 minute. Although longer response times were addressed with the current administrator, no residents or staff stated their needs were not met as a result of the wait times. The allegation: Staff do not respond to resident's call button in a timely manner is deemed unsubstantiated 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: 12/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2021
LIC9099 (FAS) - (06/04)
Page: 8 of 8