<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850365
Report Date: 04/03/2025
Date Signed: 04/03/2025 03:21:41 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/03/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250403091059
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:
04/03/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Robin MurrayTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure residents call buttons are in good repair.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
 At 12:15pm on 04/03/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the initial investigation visit to the allegation to this complaint. LPA met with Administrator, Robin Murray announced who LPA is and the reason for the visit.
LPA conducted interviews with staff and residents. LPA collected documentation relative to the allegation to this complaint and issued final findings.
As to the allegation of, “Staff does not ensure resident call buttons are in good repair.” It was alleged that, "The pendant system has been down and not working for almost 2 weeks now (04/03/2025).” It was discovered by documentation and interviews that, on 04/03/2025, LPA Jeffries conducted an interview with facility Administrator, Robin Murray who stated that approximately two weeks ago (starting about 03/17/2025) the facilities pagers, used with the signal system had intermittent problems in identifying the wrong room number of residents. On 03/25/2025 the pendant system went down. On 03/26/2025 the facility maintenance supervisor, Sergio Herrera contacted Care Worx and an IT Tech regarding pendants registering/noting the specific caller accurately. CONTINUED on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
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 3
Control Number 29-AS-20250403091059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LOMPOC
FACILITY NUMBER: 425850365
VISIT DATE: 04/03/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
 On 03/28/2025, Administrator Robin Murray contacted LPA Jeffries via email and noted that the system had been down and there is a loaner system in place on 03/26/2025, while the main system is being repaired and 1-hour checks were be conducted by facility staff. Administrator Robin Murray stated that the loaner system had also been alerting inaccurately reporting the wrong room numbers. Administrator Robin Murray noted that the pull strings in each room were also not working and reporting correctly. At this time there is enough evidence to support the allegation of, “Staff does not ensure resident call buttons are in good repair” and is substantiated at this time.

Exit interview, report read, report and appeal rights provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20250403091059
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LOMPOC
FACILITY NUMBER: 425850365
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/17/2025
Section Cited
CCR
87303(i)(1)(C)
1
2
3
4
5
6
7
87303(i)(1)(C)Facilities shall have signal systems which shall meet the following criteria:(1)All facilities licensed for 16 ...shall have a signal system which shall:(C)Identify the specific resident living unit..This requirement was not met by
1
2
3
4
5
6
7
Administrator and Maintenance Supervisor are currently programming each pendant on 04/03/2025. 8 of 32 pendants are programmed at time of investigation visit. Administrator is to check and assure all pendants are reporting accurately and report back to LPA by email on or before 04/17/2025.
8
9
10
11
12
13
14
evidence of Administrator admitting and reporting signal system malfunction. Which poses a potential risk to resident in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3