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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850365
Report Date: 11/07/2024
Date Signed: 11/07/2024 12:39:30 PM

Document Has Been Signed on 11/07/2024 12:39 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/
DIRECTOR:		MURRAY, ROBINFACILITY TYPE:
740
ADDRESS:1420 W NORTH AVENUETELEPHONE:
(805) 736-1234
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 130CENSUS: 58DATE:
11/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Robin Murray, AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 11/07/2024, Licensing Program Analyst (LPA) Brian Phillips conducted an unannounced Case Management-Deficiencies visit. LPA arrived at the facility, met with Administrator Robin Murray, and announced the purpose of the visit.

On 09/16/2024, Resident #1 (R1) sustained an unwitnessed fall while attempting to use the restroom, causing back and leg trauma. R1 stated to facility staff that they slipped and fell hurting their leg. R1 denied any pain medication and any medical treatment. The facility contacted the primary care physician for R1 who documented for the resident to continue their current plan of 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.

On 11/07/2024/2024, LPA interviewed Staff about the lack of received Incident Reports to the licensing agency regarding either the incident on 09/16/2024 or 09/19/2024 occurring in the facility. The facility above has previously been cited for deficiencies regarding reporting requirements to the licensing agency on 07/11/2024.

The facility will be cited for deficiencies regarding Reporting Requirements to the licensing agency.

Exit interview conducted, a copy of this report was 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
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 11/07/2024 12:39 PM - It Cannot Be Edited


Created By: Brian Phillips On 11/07/2024 at 09:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
12/05/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report submitted to licensing agency…within seven days...(D) Any incident that threatens welfare, safety or health of any resident
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Licensee agrees to submit Incident Reports to the Licensing Agency regarding any incident that threatens the welfare, safety, or health of any resident. The licensee will submit a plan describing how the facility will ensure reporting requirements are followed.
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This requirement was not met based on interviews and record review; licensee did not comply with section cited above when Licensing Department did not receive incident reports regarding a resident fall and physical altercation 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 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


LIC809 (FAS) - (06/04)
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