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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850365
Report Date: 05/30/2025
Date Signed: 05/30/2025 03:07:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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
12/16/2024 and conducted by Evaluator Garrett Haner-Tomasko
COMPLAINT CONTROL NUMBER: 29-AS-20241216152446
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: 59DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Resident Care Coordinator - Veronica GuineaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Due to staff neglect, residents sustained injuries while under the care and supervision of the facility.
Staff are not properly documenting incidents
Staff left residents soiled in bed for an extended period of time
Staff are not meeting residents needs
INVESTIGATION FINDINGS:
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On 5/30/2025 at 9:10am Licensing Program Analysts (LPAs) Haner-Tomasko and Jeffries conducted a subsequent complaint visit to deliver findings for the above allegations. LPAs met with Administrator Robin Murray and explained the reason for the visit. LPAs reviewed report with Resident Services Coordinator Veronica Guinea and Resident Services Supervisor Noemi Jimenez.

On 12/16/2024, the Woodland Hills North Adult and Senior Care Regional Office (RO) received a complaint regarding neglect/lack of care and supervision. The complaint alleged that multiple residents, Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4), sustained injuries while under the care and supervision of the facility. The complaint also included allegations of resident falls not being reported, staff left residents soiled in bed for extended periods of time, and staff not assisting residents during bedtime.

(Continued on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 7
Control Number 29-AS-20241216152446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC
FACILITY NUMBER: 425850365
VISIT DATE: 05/30/2025
NARRATIVE
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The complaint was referred to the Community Care Licensing Division (CCLD) Investigations Branch (IB) and assigned to Investigator Philippe Ryan Miles.

On 12/17/2024, from 1:00pm to 3:45pm, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced initial complaint investigation visit to the facility. LPA Phillips met with Administrator Robin Murray and Community Relations Director Sarah Kau and explained the reason for the visit. During the visit, the LPA conducted in-person interviews at the facility pertaining to the complaint allegations, as well as requested and received facility documentation relevant to the investigation. The LPA determined further investigation was needed prior to issuing findings.

On 12/23/2024, from approximately 1:04pm to 2:13pm, Investigator Miles and Investigator Heidy Bendana conducted interviews with Resident #1 (R1) and the resident representative for Resident #2 (R2); and on 04/13/2025, from approximately 11:54am to 2:04pm, with caregivers and med techs. The hospice residents (R2), Resident #3 (R3), and Resident #4 (R4) were not interviewed due to cognitive ability or being deceased. In addition, investigator Miles reviewed medical records from Assisted Home Health Hospice, Lompoc Valley Medical Center, Dignity Health Hospice, VNA Health Hospice, and facility file documents related to the investigation.

On 5/30/2025 from approximately 10:10am to 10:50am, LPAs Haner-Tomasko and Jeffries interviewed additional staff and administrator.

On the allegation: “Due to staff neglect, residents sustained injuries while under the care and supervision of the facility.” The investigation revealed that in October 2024, the facility increased the monthly rate for R2 due to the need of an “increase of the level of care and supervision,” however, R2 had an increase of witnessed and unwitnessed falls while sustaining multiple injuries. According to the Dignity Health Hospice medical records, it was noted R2 has had multiple falls. Caregivers stated R2 had multiple witnessed and unwitnessed falls, and behavioral episodes. Caregivers stated on one occasion, R2 went out a window, was found next door at Lompoc Skilled Nursing and Rehabilitation Center and therefore needed a higher level of care and supervision.

(Continued on LIC 9099-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 29-AS-20241216152446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC
FACILITY NUMBER: 425850365
VISIT DATE: 05/30/2025
NARRATIVE
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According to the Assisted Home Health Hospice medical records, on 12/04/2024, the Licensed Vocational Nurse (LVN) visited R3 and found multiple bruises to R3’s left shoulder. During assessment, R3 “had significant swelling and bruising to left shoulder that extended to left bicep and a bruise to [the] left wrist. Facility med tech states that there were no falls reported in the last 24 hours. Facility Administrator Robin Murray reports that she was going to investigate and interview all staff that helped with R3’s care within the last 24 hours to see if anyone forgot to write an incident report…”. On 12/05/2024, R3 was taken to Lompoc Valley Medical Center, and it was discovered during X-rays that R3 suffered an “impacted fracture on the humeral neck and fracture of the outer aspect of the humeral head with partial subluxation.” Caregivers interviewed stated R3 needed a higher level of care and supervision.

According to VNA Health Hospice medical records, it was noted that R4 was a fall-risk with having frequent multiple falls in the facility. The caregivers stated R4, who needed a higher level of care and supervision, had witnessed and unwitnessed falls in the facility in which R4 sustained injuries.

Based on the interviews conducted and supporting documents, there is sufficient evidence the facility did not provide a proper level of care and supervision to R2, R3 and R4. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: “Staff are not properly documenting incidents.” During the Department’s investigation it was revealed that R1 sustained 4 falls. R1 was admitted to the facility in July 2024 with falls occurring August, October, November and December 2024, requiring medical attention; however only 1 incident report was submitted to Community Care Licensing (CCL). In addition, R4 had falls occurring February, April, and November 2024 requiring medical attention, with no incident reports submitted. Based on the information obtained, the allegation is deemed Substantiated at this time.

On the allegations: “Staff left residents soiled in bed for extended periods of time and Staff are not meeting residents’ needs.” It was alleged staff left residents soiled in bed for extended periods of time, and staff were not assisting residents during bedtime, as some residents were observed in the early morning hours to still be in their wheelchairs and regular clothes.

(Continued on LIC9099-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 29-AS-20241216152446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC
FACILITY NUMBER: 425850365
VISIT DATE: 05/30/2025
NARRATIVE
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According to the interview conducted on 12/17/2024, the Administrator stated to LPA Phillips that the facility has had a hard time retaining and hiring employees to work there due to the location as the facility is located in an isolated town comparatively in the County. The Administrator stated that during the months of October 2024 and November 2024, a number of staff (between 5-10) had left employment at the facility due to a number of reasons including financial and geographic. The staff interviewed by the LPA stated that the facility is always hiring employees to keep staffing at an appropriate level, but it is extremely difficult due to the location. Staff also stated to the LPA that there have been "a lot" of falls in the facility in the second half of 2024. The LPA was told that it was not unusual. The LPA was also told that there is a high turnover and low retention rate at the facility, but they are always trying to keep, retain, and hire staff. Multiple staff interviewed by IB investigators indicated the facility did not have enough staffing to meet residents’ needs. Staff indicated some assisted living and memory care residents required one-on-one staff, and the facility pulled facility staff from the floor to provide additional supervision, leaving the rest of the facility short-staffed.

Additional interviews conducted with staff revealed there was not enough staffing to meet residents needs, residents were left soiled for extended period of time, and other needs such as assistance with dressing and bedtime routines were not met. Additionally, staff interviews revealed the facility call buttons were not functioning for a period of at least two weeks; this was addressed on complaint # 29-AS-20250403091059. Interviews revealed the ‘loaner’ call system was providing the incorrect room numbers. Staff also stated residents were given whistles to summon assistance, however staff could not tell which rooms the whistles were coming from, and therefore did not respond to residents.

While conducting interviews with the caregivers, they disclosed that Resident #5 (R5) eloped from the facility multiple times. R5 was discovered at a staff’s house in the neighborhood and was found near the main roads in the city of Lompoc. The local police department brought him back to the facility. Incident reports submitted by the facility revealed that R5 eloped on 07/05/2024, 08/02/2024, and 10/13/2024. R2 also eloped from the facility and was found next door at the Lompoc Skilled Nursing and Rehabilitation Center. Based on the investigation, there is sufficient evidence to support the facility did not meet resident’s needs, including residents being left soiled for an extended period of time. Based on the information obtained, the allegations are deemed Substantiated at this time.

(Continued on LIC9099-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 29-AS-20241216152446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC
FACILITY NUMBER: 425850365
VISIT DATE: 05/30/2025
NARRATIVE
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A $500 immediate civil penalty is assessed today. The Administrator was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(e) and 1569.49(f).

Pursuant to Title 22, California Code of Regulations, the following deficiencies are cited (refer to LIC9099-D).

Exit interview conducted, appeal rights and a copy of this report issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 29-AS-20241216152446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC
FACILITY NUMBER: 425850365
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2025
Section Cited
CCR
87464(d)
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Basic Services (d)...if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal…and providing the other basic services…either directly or through outside resources.
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Licensee has hired additional staffing. Adminstrator will train staff on identifying changes in condition and communicating this to leadship to update resident appraisals. Administrator will email LPA the date of this training by 5/31/2025 and the completed training and signed roster after completed.
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not provide adequate care and supervision, residents sustaining falls resulting in injuries...
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which posed an immediate health and safety risk to residents in care.
Type A
05/31/2025
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities (a) .., residents... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...to meet their needs.
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Licensee has hired additional staffing. Adminstrator will train staff on identifying changes in condition and communicating this to leadship to update resident appraisals. Administrator will email LPA the date of this training by 5/31/2025 and the completed training and signed roster after completed.
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This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they did not provide adequate staffing which resulted in residents needs not being met, including residents being left soiled for an extended period of time.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 29-AS-20241216152446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAIN SQUARE OF LOMPOC
FACILITY NUMBER: 425850365
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/13/2025
Section Cited
CCR
87211(a)(1)(B)
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Reporting Requirements(a) ... (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified in (A) through (D) below.... (B) Any serious injury as determined by the attending physician and occurring while...
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Administrator agrees to update their reporting protocol and conduct a staff training of the protocol. Administrator will email LPA documentation and a signed staff roster off all training participants on or before 6/13/2025.
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the resident is under facility supervision.

This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The Licensee did not submit incident reports for numerous falls for R1 and R4,...
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the resident is under facility supervision.
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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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7