425850365-8-23-2024-29-AS-KBUY-D8N2HJ-20240830172449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 425850365
Report Date: 08/23/2024
Date Signed: 08/23/2024 01:18:05 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 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
04/23/2024 and conducted by Evaluator Brian Phillips

COMPLAINT CONTROL NUMBER: 29-AS-20240423144138

FACILITY NAME:	FOUNTAIN SQUARE OF LOMPOC		FACILITY NUMBER:	425850365
ADMINISTRATOR:	MURRAY, ROBIN		FACILITY TYPE:	740
ADDRESS:	1420 W NORTH AVENUE		TELEPHONE:	(805) 736-1234
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY:	130	CENSUS: 63	DATE:	08/23/2024
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Sarah Kau, Community Relations Director		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff handle resident in a rough manner
Staff are not providing resident with adequate drinking water
Staff are not providing resident with adequate food service

INVESTIGATION FINDINGS:

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On 08/23/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint investigation visit to the facility above to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Community Relations Director Sarah Kau as the administrator was not available, and explained the reason for the visit.

On the allegation: Staff handle resident in a rough manner. It is alleged that Resident #1 (R1) does not like to take showers because facility staff throw R1 in the shower and scrub the wounds on R1’s left lower leg that are provided treatment by an outside Agency on a regular basis.

LPA conducted record review of facility documentation relevant to the allegation above. On 03/25/2024, a Physician Communication sent by the facility indicated that the facility staff were requesting specific Home Health Agency orders regarding the cleaning of R1’s lower left leg as R1 has cellulitis and is very combative when bathing and taking antibiotics. Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

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 4

Control Number 29-AS-20240423144138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/23/2024

NARRATIVE

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On 04/17/2024, another Physician communication sent by the facility indicated that R1 had aggressive behaviors toward staff including trying to hit Staff with their cane and attempted to slam doors into staff members. There are frequent communications between the primary physician of R1 and facility staff during March 2024 and April 2024. The primary basis for these communications is the fact that R1 is extremely physically combative and aggressive with staff as well as refusing antibiotic medications for the lower left leg injury/wound. The facility has documentation asking the primary physician of R1 for home health agency orders regarding these issues and requesting guidance. The Skilled Nursing Facility (SNF) transfer orders for R1 into the facility above on 01/12/2024 indicated that R1 has a primary diagnosis of dementia with agitation and psychosis. R1 needed supervision and assistance with Showering/Bathing Activities of Daily Living (ADL) including staff providing physical steadying assistance, lifting, holding, supporting, and providing partial/moderate assistance. Narrative charting from the facility indicated that on 03/29/2024, R1 had a staff assisted shower and stated that staff members “dunked them in chemicals.” Staff members documented that R1 had the wounds on their lower left leg cleaned and had antibiotic cream applied by staff as well as bandages. On 03/23/2024, narrative charting by the facility stated that R1 was aided in the shower and R1 stated staff “intentionally put soap in their eyes and only used cold water.” Facility narrative charting from January 2024 through March/April 2024 indicates that R1 is very disruptive and combative to both staff and other residents while eating in the dining room and in the bathroom during grooming/bathing. All staff interviewed by LPA indicated that they provided antibiotic cream to the affected wounds on R1’s lower leg and cleaned/bandaged the area but did not scrub or touch the area in a rough manner. All residents interviewed by LPA stated that they have not had any issues with staff supervision and/or assistance during ADLs including bathing and/or grooming.

Based on the information obtained, there was insufficient evidence that staff do not maintain a comfortable room temperature for resident(s). Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff are not providing resident with adequate drinking water. It is alleged that staff do not give R1 any water so R1 drinks water out of the faucet and if the faucet water were to get turned off, R1 would have to drink the toilet water.

On 05/01/2024, LPA conducted an initial 10-day complaint investigation visit to the facility above. During this visit, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA visually observed the dining/food service area as well as the kitchen area of the facility. Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 29-AS-20240423144138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/23/2024

NARRATIVE

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The LPA inspected the kitchen/food service area and observed alternating choices for breakfast, lunch and dinner daily as well as an alternate menu choice form which does not change but has a number of choices including multiple options for drinks including water, milk, juice, coffee, soda, etc. and additional requests if the facility can accommodate the request. LPA observed the dining area for residents and noticed residents being served water and juice while LPA was at the facility. All residents interviewed by LPA indicated that they receive water and/or a specific drink during each meal and have never observed any resident being refused a drink. Staff interviewed by LPA stated that residents served meals at the facility have dietary requirements which are followed. Staff stated that residents are required to complete a facility form called the Dietary Order Clarification form which lists the resident name, room number, effective date of the dietary order, the resident requirements such as regular diet, controlled carbohydrates (NCS), Approximate levels of sodium (NAS), Finger foods, meals to be cut up prior to serving, mechanical soft, Pureed food, and/or thickened liquids. The Dietary order clarification form also lists what the resident is allergic to and/or if the resident is diabetic. The form has a space to list the Special needs of the resident and is signed by the Resident Care Director, Dining Services Director of the facility, and the Primary Physician of the resident. According to all staff interviewed by LPA, the facility follows dietary guidelines by the primary physician of the resident. Staff interviewed by LPA stated the facility provides a weekly menu to residents with daily changes, as well as a set menu that is not altered. Staff stated to LPA that whenever a resident has a change of condition regarding meals, the facility will document a Dietary Order Clarification to specify what the resident's primary care physician is changing in the resident's diet. The Skilled Nursing Facility (SNF) transfer orders for R1 into the facility above on 01/12/2024 indicated that R1 has a primary diagnosis of dementia with agitation and psychosis. Narrative charting by the facility from January 2024 through March/April 2024 indicated R1 was frequently verbally aggressive to both staff and other residents including shouting accusatory remarks.

Based on the information obtained, there was insufficient evidence that staff do not maintain a comfortable room temperature for resident(s). Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Staff are not providing resident with adequate food service. It is alleged that staff only give Resident #1 (R1) vegetable soup to eat for every meal and R1 is tired of it. It is also alleged that staff only give R1 vegetable soup to eat because of R1’s teeth and dentures.

On 05/01/2024, LPA conducted an initial 10 day complaint investigation visit to the facility above. During this visit, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. LPA visually observed the dining/food service area as well as the kitchen area of the facility. Continued on 9099-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 29-AS-20240423144138

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 08/23/2024

NARRATIVE

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The LPA inspected the kitchen/food service area and observed perishable food items in good condition, with proper expiration dates precluding the perishable items from expiring. The facility has a sufficient supply of perishable and non-perishable food, which was observed by LPA in the kitchen area of the facility. The freezer and refrigerator were both the appropriate temperate Fahrenheit for the storage of food and prevention of spoiling. Staff interviewed by LPA stated that residents served meals at the facility have dietary requirements which are followed. Staff stated that residents are required to complete a facility form called the Dietary Order Clarification form which lists the resident name, room number, effective date of the dietary order, the resident requirements such as regular diet, controlled carbohydrates (NCS), Approximate levels of sodium (NAS), Finger foods, meals to be cut up prior to serving, mechanical soft, Pureed food, and/or thickened liquids. The Dietary order clarification form also lists what the resident is allergic to and/or if the resident is diabetic. The form has a space to list the Special needs of the resident and is signed by the Resident Care Director, Dining Services Director of the facility, and the Primary Physician of the resident. According to all staff interviewed by LPA, the facility follows dietary guidelines by the primary physician of the resident. Staff interviewed by LPA stated the facility provides a weekly menu to residents with daily changes, as well as a set menu that is not altered. Staff stated to LPA that whenever a resident has a change of condition regarding meals, the facility will document a Dietary Order Clarification to specify what the resident's primary care physician is changing in the resident's diet. According to Staff and verified by LPA during facility record review on 05/01/2024, the Dietary Order Clarification dated 01/12/2024 for Resident #1 (R1) stated that according to the physician of R1, the resident requires all meals to be Pureed. This form was signed off on by the physician for R1 and facility staff. Staff stated to LPA that regarding meals for residents, there is a weekly menu which has alternating choices for breakfast, lunch and dinner daily as well as an alternate menu choice form which does not change, but has a number of choices including salads, items from the grill, items from the deli section, and additional requests such as yogurt or ice cream. Staff interviewed by LPA stated that R1 had recently seemed upset about the choices of food and had told staff that they preferred vegetarian choices. Staff stated to LPA that there is no record of R1 being a vegetarian by any physician orders, but that R1 was accommodated with vegetarian options of meals. LPA corroborated this accommodation to vegetarian options through record review of R1’s Dietary Order Clarification form and weekly menu guidelines.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Brian Phillips	TELEPHONE: (805) 956-1636
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4