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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850365
Report Date: 07/11/2024
Date Signed: 07/11/2024 02:43:35 PM


Document Has Been Signed on 07/11/2024 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:FOUNTAIN SQUARE OF LOMPOCFACILITY NUMBER:
425850365
ADMINISTRATOR:MURRAY, ROBINFACILITY TYPE:
740
ADDRESS:1420 W NORTH AVENUETELEPHONE:
(805) 736-1234
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY:130CENSUS: 68DATE:
07/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Sarah Kau, Community Relations DirectorTIME COMPLETED:
03:00 PM
NARRATIVE
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On 07/11/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a case management-deficiencies visit to the facility above. During the visit, LPA Phillips met with Community Relations Director Sarah Kau as the Executive Director/Administrator of the facility was unavailable at the time, and explained the reason for the visit. During the complaint investigation of complaint # 29-AS-20240627081510, the following deficiencies were observed:

There were no incident reports submitted for Resident #1 (R1’s) hospitalizations on 06/02/2024 and 06/11/2024 due to non-epileptic seizures caused by oral medications prescribed to R1 for cancer treatment in combination with radiation chemotherapy. There was no incident report submitted to Licensing on 06/12/2024 due to R1 being observed unresponsive and with no pulse by facility staff. There was no death report submitted for R1’s Death on 06/13/2024 while in the Critical Care Unit (CCU) of the hospital. R1’s representative was notified of R1’s hospitalizations and subsequent death. The facility acted appropriately in each instance to provide R1 appropriate medical attention. However, the licensee did not notify Licensing of the incidents or the death of R1.

Exit interview, deficiencies cited, report given, appeal rights given.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/11/2024 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC
FACILITY NUMBER: 425850365

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2024
Section Cited
CCR
87211(a)(1)(A),(B)

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87211a(1)(A),(B) Reporting Reqs. Licensee shall furnish to licensing agency...including...(1) Written report to licensing agency…within 7 days…(A) Death of resident...regardless where death occurred...(B) Any serious injury determined by attending physician..occurring to resident under facility supervision
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The licensee will submit a plan describing how the facility will ensure reporting requirements are followed. Submit proof to Community Care Licensing Division (CCLD) by 08/08/2024
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This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with the section cited above. Licensee did not submit incident reports for R1's hospitalizations or death report for R1, which posed a potential 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: Brian PhillipsTELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:
DATE: 07/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/11/2024
LIC809 (FAS) - (06/04)
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