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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850365
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:42:41 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
10/07/2024 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20241007151923
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: 58DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Robin Murray, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Due to lack of supervision, resident hit resident
INVESTIGATION FINDINGS:
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On 11/07/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint investigation visit to deliver final findings for the above allegation. During this visit, LPA met with Administrator Robin Murray and explained the reason for the visit.

On the allegation: Due to lack of supervision, resident hit resident. It is alleged that when R1’s responsible party visited them in care at the facility they were not properly supervised. It is also alleged that the responsible party of Resident #1 (R1) was contacted by the facility to inform them that R1 had been hit by another resident in care. When R1’s responsible party visited the facility after receiving this information, they observed R1 with a bruised and swollen face, allegedly from being hit by another resident.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
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 6
Control Number 29-AS-20241007151923
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: 11/07/2024
NARRATIVE
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LPA confirmed through interview and record review that R1 was admitted to the facility above on 08/29/2024 and discharged by their responsible party on 09/19/2024. LPA requested and received Documented Narrative Charting by the facility for R1 while in care. On 09/19/2024, staff documented that R1 was involved in an altercation with another resident. According to facility staff, R1 was struck by another resident in the face which caused R1 to begin bleeding. Facility staff documented that an incident report was completed, but the Licensing Agency has not received any unusual incident/injury report (UIR) regarding R1 while in care. Through interview with LPA, it was stated that the responsible party of R1 visited the facility in September 2024 and observed R1 outside in the courtyard area of the facility wearing little clothing and shivering due to the cold. Staff documented in facility narrative charting that upon admission on 08/29/2024 R1 was an elopement/wandering risk. The Needs and Services Plan for R1 states the need for standby assistance from staff due to R1 being a falling risk and that R1 needs secure memory care due to a history of wandering and exit seeking behavior. Staff found R1 sleeping in another resident’s room on multiple occasions including 08/29/2024 and 08/31/2024. Staff also stated that on 09/10/2024, R1 needed to be redirected multiple times to leave another resident’s room after staff were notified by another resident that R1 was in their room. According to facility staff and narrative charting, on 09/16/2024, R1 had an unwitnessed fall while attempting to use the restroom alone. The Licensing Agency did not receive any unusual incident/injury report (UIR) for R1 while in care including the unwitnessed fall incident on 09/16/2024, nor the physical assault by another resident on 09/19/2024. Facility documentation states the need for R1 to have enhanced supervision due to being a falling risk as well as an elopement/wandering risk. However, multiple incidents involving R1 occurred in the facility which would not have happened with appropriate supervision by staff.

Based on the information gathered, there is sufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Substantiated.

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

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
10/07/2024 and conducted by Evaluator Brian Phillips
COMPLAINT CONTROL NUMBER: 29-AS-20241007151923

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: 58DATE:
11/07/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Robin Murray, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not meet resident's needs
Staff overmedicated resident
Staff did not safeguard resident's belongings
INVESTIGATION FINDINGS:
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On 11/07/2024, Licensing Program Analyst (LPA) Brian Phillips conducted a subsequent complaint investigation visit to deliver final findings for the above allegation. During this visit, LPA met with Administrator Robin Murray and explained the reason for the visit.

On the allegation: Staff did not meet resident’s needs. It is alleged that when R1’s responsible party visited them in care at the facility they had not been assisted in bathing/showering with a strong odor. R1 was allegedly wearing other residents’ clothes and their own clothes were soiled.

Through interview with LPA, it was stated that the responsible party of R1 visited the facility in September 2024 and observed R1 with oily greasy hair and smelling terribly like they hadn't been bathed. R1’s responsible party stated they bathed/showered R1 outside of the facility after discharge on 09/19/2024. Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 29-AS-20241007151923
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: 11/07/2024
NARRATIVE
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R1's responsible party stated that when they bathed R1 after discharge, there was dried feces all over the backside of R1. Documented Narrative Charting by the facility for R1 stated that on 09/18/2024, R1 was observed by staff to have soiled themselves in bed, which soaked through their mattress. R1’s resident assessment and R1’s needs and services plan both indicated that R1 required stand by assistance while bathing/showering 7 times per week. The resident assessment also stated that R1 bathes themselves with standby assistance daily in the afternoon. All staff interviewed by LPA indicated that resident assessments are followed, and all residents are bathed/showered regularly. All residents interviewed by LPA indicated they are bathed appropriately at the facility. LPA observed residents in the facility during complaint investigation visits on 10/11/2024 and 11/07/2024. During both visits, LPA did not observe any residents with dirty clothing, unwashed/greasy hair, and did not smell any noticeably unpleasant odors on any resident.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

On the allegation: Staff overmedicated resident. It is alleged that relatives of R1 felt they were overmedicated by the facility while in care due R1’s observed physical and mental state.

LPA requested and received medical information for R1 while in care at the facility including the current medication record for R1 maintained by their primary care physician (PCP). LPA also received the medication orders and instructions provided by R1’s PCP with the listed medications prescribed dosage, symptom/reason, and quantity. LPA conducted record review of the individual narcotic record for R1 while in care at the facility. The individual narcotic record provides the name and directions for the medication, date and time provided, dosage, staff signatures, and amount remaining. LPA additionally reviewed the centrally stored medication and destruction record for R1 while in care at the facility as well as the medication release documentation for overnight visits and respite discharges. Record review of all medication information provided by both the facility and the PCP of R1 showed no evidence of any overmedication occurring by the facility to R1.

Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

Continued on 9099-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 29-AS-20241007151923
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: 11/07/2024
NARRATIVE
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On the allegation: Staff did not safeguard resident’s belongings. It is alleged that when R1’s responsible party visited the facility in September 2024, R1’s shoes were missing and R1 was allegedly wearing other residents’ clothes. It is also alleged that R1’s responsible party brought a lot of clothing and belongings to have in the facility prior to admission. However, when R1 was discharged, the facility could not find any of R1's belongings and they were never returned.

LPA requested and received the contents of R1’s facility file/record. However, there was no documented LIC 621 form Resident Personal Property and Valuables. LPA interviews with facility staff stated that R1 and/or their responsible party declined to provide a documented inventory upon entry into the facility. All staff interviewed by LPA stated that R1 had the items/belongings in their bedroom returned to them upon discharge from the facility on 09/19/2024, and that any item which could not be found was replaced promptly by the facility. LPA found no evidence through all interviews in the facility and record review of facility documentation that staff did not return R1’s belongings or replace R1's belongings upon discharge from the facility. Facility staff stated to LPA that a pair of R1's shoes were unable to be located, but stated that staff purchased a replacement pair of shoes for R1. LPA was provided evidence that R1 had their shoes replaced by the facility in an appropriate time frame. LPA additionally interviewed facility staff about R1 wearing other residents’ clothes while in the facility, but all staff interviewed stated that they did not witness R1 wearing other residents’ clothes. Facility narrative charting did document that R1 occasionally slept in other residents’ rooms and would have to be redirected to leave other residents rooms on multiple occasions, but there is no documentation of R1 wearing other residents clothing.
Based on the information gathered, there is insufficient evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

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

DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 29-AS-20241007151923
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: 11/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/08/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Add’tl Personal Rights of Residents…(a) …residents in...RCFE shall have all following personal rights: (4) To care, supervision, and services that meet individual needs delivered by staff sufficient in numbers, qualifications, and competency to meet needs.
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The licensee will take appropriate measures to maintain and increase staffing in the facility. Licensee will also provide training to all staff on resident personal rights including supervision and neglect.
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This requirement is not met based on interviews and record review, licensee did not comply with the section cited above when staff failed to provide appropriate supervision to Resident #1 resulting in multiple incidents 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.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6