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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850365
Report Date: 07/10/2025
Date Signed: 07/10/2025 12:22:51 PM

Document Has Been Signed on 07/10/2025 12:22 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: 51DATE:
07/10/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Administrator, Robin MurrayTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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 At 9:15am on 07/10/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct a case management visit pertaining to Serious Incident Reports (SIR) from the facility, reviewed from March 2025 through June 2025. Upon arrive to the facility and entering at 9:15am there were no staff at the entrance, LPA singed in and walked into the facility. LPA walked down to the left side hallway and discovered the Med room unlocked and unattended. LPA called Administrator by phone and left a message on Administrators cell phone. LPA met with Resident Care Coordinator, Veronica Guinea (RCC),, announced who he is and the reason for the visit.

LPA Jeffries took a short video of the unsecured medication room searched and found staff and asked staff to secure medication room. LPA noted that there were 5 residents in the dining room and 2 residents walking the hallway near the medication room when LPA discovered the unsecured and open medication room. LPA called Administrator on cell phone to request her presents at the facility at 9:30am. Facility will receive citation, 87465(h)(2) Incidental Medical and Dental Care, medications accessible to persons other than responsible employees.

LPA Jeffries reviewed SIR's from the facility during the months of March 2025 through June 2025 and noted at least 18 SIR's with late and/or missing information as required by Community Care Licensing (CCL) Regulations 87211. LPA Jeffries noted that there were two verbal warning by LPA Jeffries to Administrator, Robin Murray about regulation reporting requirements of SIRs being submitted past the 7 days within the occurrence to report regulation requirements (87211(a)(1)), on 04/03/2025 and 04/30/2025.

CONTINUED on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/10/2025 12:22 PM - It Cannot Be Edited


Created By: Mark Jeffries On 07/10/2025 at 08:12 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: 07/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2025
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:
(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally
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Administrator agrees to reevalute and update medication securty policy and send update to LPA by 07/11/2025.
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 stored medication. This requirement was not met by observation of LPA discovering open and unsecured medication room with no staff present. This poses an eminent danger to residents in care.
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Type B
07/24/2025
Section Cited
CCR87211(a)(2)

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven
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Administrator agrees to contact hospital (ER) administrator and clarifiy discharge requiorments when a resieent is released back to the facility from the ER. Aministrator will request email of outcome and forward that email to LPA by 07/24/2025.
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days of the occurrence ...This report shall include...attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met was not met in 18 of 105 and 7 of 105 SIRs submitted in March through June of 2025, which poses a potential risk to Residents.
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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.
Kelly Burley
NAME OF LICENSING PROGRAM MANAGER:
Mark Jeffries
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/10/2025
NARRATIVE
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LPA Jeffries followed up with an written warning of late SIRs in an email sent to Administrator on 06/18/2025, and followed up with an email to Administrator of copy of CCL 87211 reporting requirements sent to Administrator on 06/20/2025. In reviewing SIRs dated from March 2025 through June 2025 LPA noted that there were 105 SIRs submitted by the facility. 18 of 105 were submitted after the 7 day requirement. LPA also noted that 7 of 105 SIR's had no attending physician's name, findings, and treatment, if any; and disposition of the case when residents had returned from the Emergency Room (ER) visits. On 07/03/2025 LPA requested ER discharge paperwork for an incomplete SIR dated 06/24/2025. LPA noted that the ER discharge paper work was incomplete and contacted Administrator on 07/02/2025 by phone to reviewed CCL Regulations reporting requirements. Based on 18 of 105 SIRs in March 2025 through June 2025 being submitted past 7 days of the occurrence, and 7 of 105 SIRs review during that time not having attending physician's name, findings, and treatment, if any; and disposition of the case when residents returned from the Emergency Room, a citation is issued.


Exit interview, report read, appeal rights and report provided.
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2025
LIC809 (FAS) - (06/04)
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