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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425802104
Report Date: 09/23/2022
Date Signed: 09/23/2022 04:11:39 PM

Substantiated


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
05/24/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220524120354
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:130CENSUS: 63DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robin Murray, Administrator and Jessica Ramirez, Memory Care DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Due to staff neglect, resident sustained injury while in care
Staff did not safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Robin Murray and explained the reason for the visit.

The investigation was started on 5/26/2022 by LPA Darlene Chavez. LPA requested relevant documents on 5/26/2022. LPA Olson conducted a subsequent visit to the facility on 9/21/2022 to continue the investigation. LPA Olson requested documents and interviewed staff, residents, and administrator on 9/21/2022.

On the allegation: Due to staff neglect, resident sustained injury while in care. On 05/24/2022, the Department received a complaint alleging that staff neglected/failed to provide supervision for Resident 1 (R1) by failing to put R1’s bed rail into an upright position, resulting in a fall causing a skin tear on R1’s left arm, a cut on right hand, and bleeding of upper left eye. The complaint was referred to Community Care Licensing (CCL) Investigations Branch (IB) and assigned to Investigator Christine Ferris.
Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 6
Control Number 29-AS-20220524120354
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: 09/23/2022
NARRATIVE
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On 05/26/2022, from 10:46am to 11:40am, Licensing Program Analyst (LPA) Darlene Chavez conducted an unannounced 10-day complaint visit to the facility. LPA Chavez met with Fatima Magallon, Business Office Manager, and explained the purpose of the visit. LPA requested copies of the resident roster and staff schedule.

On 06/10/2022, Investigator Ferris conducted interviews with facility staff and residents; on 06/20/2022, with the Administrator and staff; on 07/08/2022, attempted to contact Staff #1 (S1); and on 07/18/2022, with staff. Additionally, the Investigator obtained copies of R1’s facility file record, photos of R1’s bed showing full bed rails, and Dignity Home Health and Hospice medical records.

A review of R1’s records revealed that R1 is non-ambulatory, a fall risk, requires total assistance with meals, toileting, ambulation, and needs a two person assist with transfers. Per the 03/16/2022 Physician Report, R1’s diagnosis is listed as Alzheimer’s Disease. Investigator Ferris reviewed a letter dated 05/14/2021 from Dignity Health stating R1 “must have a bed rail in place and it is not to be removed unless by the direction of a physician”. R1 was placed on hospice on 05/27/2021.

Investigator Ferris reviewed the Dignity Health Hospice sign in sheet and hospice documentation notes. The notes document that on 05/12/2022, R1 was found on the floor at 4:30am with injuries. Staff contacted the hospice nurse and stated the bed rail was in the down position and the fall was due to staff not raising the bed rail at last patient check. R1 sustained a bump above left eye, a skin tear to left arm and a cut to right hand. The hospice nurse arrived and treated the injuries. R1 was provided Tylenol, an ice pack for the bump above eye and the other two areas were cleaned and covered with a bandage. The documentation dated 06/06/2022, indicates in summary that R1’s left forearm bandage was changed, injury almost healed, and R1 continued to show decline as anticipated.

The investigation provided sufficient evidence to substantiate neglect/lack of supervision against the facility staff. Per the staff interviews, R1’s bed rail was observed to be in a down position when R1 was found on the floor of R1’s room. Per the staff, it is not possible for R1 to lift or move self over the bed rail, nor is it possible for R1 to maneuver the position of the bed rail by self. Per the Dignity Health Hospice records, it was reported to them on 05/12/2022 that R1’s bed rail was left in a down position resulting in R1 falling to the floor and sustaining injuries. Therefore, the allegation is Substantiated at this time.
Continued on 9099-C
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20220524120354
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: 09/23/2022
NARRATIVE
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On the allegation: Staff did not safeguard resident's personal belongings. LPA Olson interviewed staff, administrator and residents on 9/21/2022, and interviewed R1’s responsible party on 9/21/2022. It was alleged that R1’s bed rails and wheelchair legs to the hospital bed were missing. LPA interviewed R1’s responsible party, who stated the family provided bed rails and the bed rails went missing, but were later replaced. R1’s responsible party also stated R1’s wheelchair legs were missing. LPA interviewed staff and administrator, who stated they were aware that R1’s wheelchair legs went missing at one point, but the facility found a replacement set of wheelchair legs and provided them to R1. Residents and staff interviewed indicated no other items had gone missing at the facility. Based on the information obtained, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC 9099-D).

For the injury R1 sustained, an immediate civil penalty of $500 is warranted in accordance with California Health and Safety Code Section 1569.49(c)(1).

Exit interview conducted, appeal rights discussed, a copy of this report, deficiency page, civil penalty and appeal rights issued via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 29-AS-20220524120354
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: 09/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2022
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Residents in...residential care facilities for the elderly shall have all of the following personal rights: To care, supervision, and services that meet their individual needs and are delivered by staff...to meet their needs. This requirement is not met as evidenced by:
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S1 no longer works at the facility. Administrator agreed to conduct staff training on bed rail safety. Submit training records to CCL by 9/24/22.
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Based on interviews and records review, the licensee did not comply with the section cited above when staff failed to put R1’s bed rail in an upright position, resulting in R1 falling and sustaining injuries, 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: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
05/24/2022 and conducted by Evaluator Jeannette Olson
COMPLAINT CONTROL NUMBER: 29-AS-20220524120354

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:130CENSUS: DATE:
09/23/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robin Murray, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility does not have sufficient staffing
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Olson conducted a subsequent complaint visit to deliver findings for the above allegations. LPA met with Administrator Robin Murray and explained the reason for the visit.

The investigation was started on 5/26/2022 by LPA Darlene Chavez. LPA requested relevant documents on 5/26/2022. LPA Olson conducted a subsequent visit to the facility on 9/21/2022 to continue the investigation. LPA Olson interviewed staff, residents, and administrator on 9/21/2022.

On the allegation: Facility does not have sufficient staffing: LPA Olson reviewed staff schedules, interviewed residents, and interviewed staff and administrator. All residents interviewed indicated their care needs were met by staff. Staff interviewed indicated they could use more staff at the facility, but in the meantime staff ensured residents’ needs were met through teamwork and by working overtime. In addition to the med tech and caregiver listed on the schedule, the Administrator, nurse, and memory care director step in to provide direct care assistance or medication assistance as needed. Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
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 6
Control Number 29-AS-20220524120354
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: 09/23/2022
NARRATIVE
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Administrator stated they were in the process of hiring and onboarding new staff, and they were having former staff return. Administrator stated they was conscious of staff working too much and could get burned out, so the facility was prioritizing hiring additional staff. LPA requests that the master schedule be updated to show the additional care coverage provided on each shift by management staff. Due to insufficient evidence, the allegation could not be proven at this time. Therefore the allegation is deemed Unsubstantiated at this time.

Exit interview, report issued via email.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6