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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850365
Report Date: 03/17/2025
Date Signed: 03/17/2025 05:33:01 PM

Document Has Been Signed on 03/17/2025 05:33 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
CCLD Regional Office, 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: 57DATE:
03/17/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:00 PM
MET WITH:Community Relations Director, Sarah KauTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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 At 4:00pm on 03/17/2025, Licensing Program Analyst (LPA) Jeffries arrived at the facility unannounced to conduct an Case Management Visit pertaining to the incident and subsequent reports on 03/09/2025 at approximately 9:15pm of Resident 1 (R1). LPA met with Community Relations Director, Sarah Kau (S1) announced who he is and the reason for the visit. LPA requested R1 full file including but not limited to R1’s LIC602 (Physicians Reports), Pre Admissions appraisal, Appraisals Needs and Services Plan, Resident contact information, and all resident file information. S1 and LPA conducted a physical tour of the facility and took photographs. There is no further information to report on this Case Management Visit.

Exit interview, report read, and report provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 03/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/17/2025
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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