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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850365
Report Date: 09/03/2024
Date Signed: 09/03/2024 03:24:00 PM

Substantiated


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
04/10/2024 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20240410083709
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: 63DATE:
09/03/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robin Murray, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff did not meet resident's needs
Facility has insufficient staffing
Facility did not contact responsible party about a change in condition
Facility is not reporting incidents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent case management-incident investigation visit to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Robin Murray and explained the reason for the visit.

On the allegation: Facility staff did not meet resident’s needs. It is alleged that a visitor to the facility observed a long stream of water running down the hallway coming from the shower door in the facility. Allegedly there was no response when the visitor knocked on the shower door, and facility staff could not be located. When staff were finally located, Resident #1 (R1) was on a shower chair, with two (2) inches of water on floor. R1’s washcloth had fallen on the drain. Allegedly facility staff stated R1 was fine, and very independent. It is alleged that if R1 passed out and fallen they would have drowned. Staff stated R1 was there for approximately five (5) minutes, but other accounts allegedly said 20-25 minutes is how long it would have taken to flood that much. Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
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 8
Control Number 29-AS-20240410083709
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: 09/03/2024
NARRATIVE
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On 04/12/2024, LPA conducted an initial facility site visit for a complaint investigation into the allegations above. LPA interviewed residents, staff, and conducted record review of relevant documentation to the allegations. According to staff interviewed by LPA, on 03/28/2024, R1 had asked staff to get blankets because they were in cold water for a while. Staff interviewed by LPA stated they couldn’t tell how long R1 was in the shower. The staff stated to LPA that R1 was not unconscious or slumped over, but just was in cold water for a brief period. Staff interviewed by LPA stated that R1 should not have been in that shower location because it’s supposed to be closed as the drain clogs. The administrator of the facility stated R1 wasn’t supposed to be in that location, and that R1 has been told not to use that shower before, because it’s broken. The administrator additionally said R1 was taking a shower and dropped the washcloth. Staff stated to LPA that after the shower incident R1 was in their room with numerous blankets on, shivering. Staff interviewed by LPA stated that R1 had been in the shower, freezing cold, trying to warm up. Staff stated to LPA that R1 should never have ambulated from their room to the shower, with no walker present.

LPA requested and received relevant facility documentation pertinent to the allegation. Through record review, the Physician’s Report for R1 dated 01/30/2024 states that R1 has the capacity for self-care including bathing and dressing/grooming. R1 has a secondary diagnosis of unspecified visual loss as well as a history of falls documented in the Physician’s Report. The mental condition of R1 is listed as confused/disoriented, but R1 has no documented wandering, aggressive, sundowning, or inappropriate behavior according to the Physician’s Report. Additionally, R1 has a documented physical health status of motor impairment/paralysis with an unsteady gate and refusal to use a walker. The Resident Appraisal of R1 dated 02/03/2024 states that R1 can care for themselves physically with the ability to understand and communicate their needs. The 02/03/2024 Resident Appraisal of R1 does state that R1 has had a decline in mental condition and cognitive changes. R1 is also documented to need required grab bars in the bathroom for safety but does not need help with bathing. However, the Resident Appraisal states that R1 does need help setting up a new environment when bathing. The 03/09/2024 Needs and Services Plan for R1 indicates that R1 has independent bathing during the morning (AM) everyday Monday-Friday. R1 is listed as able to shower on their own. Staff do need to set up the shower to ensure safety in a new environment. Staff will monitor R1’s hygiene for changes and staff should notify the home health agency representative if R1 requires assistance. R1 moved into the facility on 02/04/2024 due to anticipated decline related to a diagnosis of cancer and hospice needs. The Assisted Living Advantage Resident Assessment for R1 dated 01/25/2024 states that R1 bathes independently and showers on their own without reminders, stand-by assistance from staff, or total assistance from staff. Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 29-AS-20240410083709
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: 09/03/2024
NARRATIVE
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Documented Narrative Charting by the facility indicates that on 03/25/2024, R1 stated to staff that they fell out of their bed but denied any pain. The narrative charting states that R1 needs to be checked on more often. On 03/28/2024, R1 received a hospital bed and requires full assistance including the changing of briefs. Also, on 03/28/2024 narrative charting stated R1 was found on the ground in the bathroom, looked “out of it” and very pale. Home health agency services were requested. On 03/29/2024, R1 was found on the floor by the kitchen area of the facility and helped back to their bed by staff. Additionally, on 03/29/2024, R1 was found multiple times trying to walk around their room with an unsteady gait and lacking balance. A bedside commode had been ordered for R1 a week prior to the 03/28/2024 incident in the shower. According to interviews by LPA, the facility had installed the commode on top of the toilet without the basket. Eventually the basket was found, and staff were educated it should be bedside. R1 received a hospital bed and staff were informed to make sure the bedrails were up. On 03/29/2024, R1 fell out of the hospital bed, and staff were again informed the bedrail needs to be up on the bed. Staff were educated by home health agency representative on how to keep bedrail up, check on R1, and turn R1. Home health agency also provided a bed alarm for R1. On 04/04/2024, R1 had another fall from the bed with the bedrail not up as instructed and no alarm. The facility administrator stated that the bed alarm is not working anymore for R1, and they must have taken the battery out themselves. On 04/10/2024, Witness #1 (W1) visited the facility and observed R1 uncovered by their blanket, with a bruise on their hip. W2 stated to LPA that when asked about the bruise, R1 stated that they had fallen again. W1 stated to LPA that the bed alarm is supposed to be attached to R1’s bed, but it was under bed with the battery cover open and battery gone. Staff were unable to find batteries or cover piece for bed alarm. W1 stated to LPA that they were told by the administrator that R1’s home health agency needed to provide another alarm. W1 stated to LPA that they observed the bedrails on R1’s hospital bed not in the highest position and were crooked. W1 stated that R1 would not be able to move the bedrails on their own.

Based on the information obtained, there is sufficient evidence that facility staff did not meet resident’s needs. Therefore, the allegation is deemed Substantiated at this time.

On the allegation: Facility has insufficient staffing. It is alleged that the facility is understaffed which is detrimental to the care of residents. The allegation states that if the facility feels that they do not have enough staff to provide the care R1 needs, they need to alert outside agencies. It is alleged that there are not enough staff in the facility, and it was not a good idea for R1 to have moved in. Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 29-AS-20240410083709
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: 09/03/2024
NARRATIVE
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On 04/12/2024, LPA conducted an initial complaint investigation visit to the facility above. During this visit, LPA requested and received relevant facility documentation pertinent to the allegation. Through record review of the facility staff roster and the facility staff schedule, as well as LPA interviews with current staff, LPA was informed that the facility has been in the process of a staffing hire for multiple positions throughout 2024. The facility staffing hire was stated to LPA to be in response to vacant employment positions in the facility. On 08/29/2024, LPA conducted a subsequent complaint investigation visit and observed facility postings advertising hiring positions. Staff interviewed stated that many new positions have been hired in the facility in June and July of 2024. This was corroborated through record review of the current staff roster and schedule during the 08/29/2024 visit by LPA. Through staff interview by LPA, the facility is aware of the disadvantages of being potentially understaffed and have been actively trying to correct this through hiring multiple new employees. No resident interviewed by LPA in either the Assisted Living or Memory Care portion of the facility indicated that any of their Activity of Daily Living (ADL) needs are not being met by facility staff due to a lack in staffing.

Based on the information obtained, there is sufficient evidence that the facility has insufficient staffing. Therefore, the allegation is deemed Unsubstantiated at this time.

On the allegation: Facility did not contact responsible party about a change in condition. It is alleged that the facility did not inform the Power of Attorney (POA) for Resident #1 (R1) about a change in condition. The allegation states that R1 was independent when admitted into the facility, but is no longer independent.

Through record review, LPA learned through the Physician’s Report for R1 dated 01/30/2024 that R1 has the capacity for self-care including bathing and dressing/grooming. On 03/28/2024, R1 experienced an incident regarding lethargy and disorientation while bathing/showering. R1 then agreed to a home health agency evaluation and a change in postural supports as well as medication. Through interview and record review by LPA, on 04/03/2024 the POA for R1 was contacted by Witness #2 (W2) regarding a change in condition for R1. The POA for R1 was unaware of the incident regarding R1 on 03/28/2024 or R1’s change in condition. Staff indicated R1 was lethargic due to home health agency hospice care. On 03/31/2024, W2 visited the facility and observed R1 in bed and lethargic. Through interview with staff, LPA was told that R1 was declining and needed an evaluation by a home health agency. W2 tried to confirm the POA of R1 would be aware of the change in condition. Through interview by LPA, it was stated the home health agency representative let the POA of R1 know about the change in condition. Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 29-AS-20240410083709
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: 09/03/2024
NARRATIVE
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 W2 informed the facility that the POA needs to be informed of a change of condition by the facility as well. Based on LPA interviews with staff and records review, facility staff seemed unaware on the need for the facility to inform the responsible party of R1 about a change in condition.

Based on the information obtained, there is sufficient evidence that the facility did not contact responsible party about a change in condition. Therefore, the allegation is deemed Substantiated at this time.



On the allegation: Facility is not reporting incidents. It is alleged that multiple service providers from agencies collaborating with the facility believe the facility does not appear to be reporting incidents to Community Care Licensing Division (CCLD).

Through interview with facility staff and home health agency service providers, LPA learned that Resident #1 (R1) had multiple falls on 03/29/2024, and a fall on 04/04/2024. CCLD has not received any Unusual Incident/Injury Reports (UIR) for any alleged falls in care since R1 was admitted into the facility above on 02/04/2024. On 02/09/2024, the Department received a self-reported Unusual Incident/Injury Report (UIR) regarding R1, but it did not concern any fall or injury in care at the facility. On 07/11/2024, LPA conducted a case management-deficiencies visit to the facility above. During the complaint investigation of complaint # 29-AS-20240627081510, the following deficiencies were observed: There were no incident reports submitted for Resident #2 (R2’s) hospitalizations on 06/02/2024 and 06/11/2024 due to non-epileptic seizures caused by oral medications prescribed to R2 for cancer treatment in combination with radiation chemotherapy. There was no UIR submitted to the Department on 06/12/2024 due to R2 being observed unresponsive and with no pulse by facility staff. There was no death report submitted for R2’s Death on 06/13/2024 while in the Critical Care Unit (CCU) of the hospital. Based on interviews and records review, licensee did not submit incident reports for R1’s falls while in care, R2's hospitalizations, or death report for R2.

Based on the information obtained, there is sufficient evidence that the facility is not reporting incidents. Therefore, the allegation is deemed Substantiated at this time.

Exit interview conducted. A copy of this report has been provided to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
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
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
04/10/2024 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20240410083709

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: 63DATE:
09/03/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Robin Murray, AdministratorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility staff do not respond to call buttons timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent case management-incident investigation visit to deliver final findings for the above allegations. During today’s visit, LPA Phillips met with Administrator Robin Murray and explained the reason for the visit.

On the allegation: Facility staff do not respond to call buttons timely. It is alleged that there are delays by facility staff members in answering the call button(s) for residents. It is alleged that staff attempt to answer the call buttons pressed in the facility, but they don’t respond quickly.

During the complaint investigation facility site visits by LPA on 04/12/2024 and 08/29/2024, LPA did not observe any staff member delaying or deliberating refusing to answer any call button. LPA observed staff receiving call button alerts and attempting to attend to the issue in a prompt matter. Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
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-20240410083709
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: 09/03/2024
NARRATIVE
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No resident interviewed by LPA stated that facility staff members do not respond to call buttons timely. All residents interviewed stated that when a call button is pressed a staff member will respond to their needs. Residents stated to LPA that waiting times can vary depending on the time of day a call button is pressed, but there are not any delays that have inconvenienced the residents. During the 04/12/2024 initial complaint investigation visit to the facility above LPA attempted to request a documented call log from the facility listing date, time, wait length of call button responses by Staff. LPA was told that the facility did not have a documented log of call button responses for the facility. All staff members of the facility interviewed by LPA stated they make every attempt to answer call buttons in a prompt manner with no delays.

Based on the information obtained, there is insufficient evidence that facility staff do not respond to call buttons timely. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of this report provided to the facility.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 29-AS-20240410083709
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements-General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... to ensure provision of personal assistance and care
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The licensee has shown LPA appropriate measures to maintain and increase staffing in the facility, including job advertisements observed by the LPA.
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This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to have sufficient staff to meet the needs of residents, which posed a potential health and safety risk to residents in care.
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Type B
10/01/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Reqs. Licensee shall furnish to licensing agency...including...(1) Written report submitted to licensing agency and to person responsible for resident within 7 days… (D) Any incident which threatens the welfare, safety or health of any resident…
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The licensee has submittted a plan describing how the facility will ensure reporting requirements are followed. Submit proof to Community Care Licensing Division (CCLD).
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This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to report an incident and change of condition in R1 to licensing and responsible pary, 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 8