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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 425850365
Report Date: 08/01/2025
Date Signed: 08/01/2025 11:12:32 AM

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
06/24/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250624093140
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: 52DATE:
08/01/2025
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Resident Care Coordinator, Veronica GuineaTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility did not answer residents call button in a timely manner.
INVESTIGATION FINDINGS:
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 At 9:40 AM on 08/01/2025, LPA Jeffries arrived unannounced to issue final findings to the allegations to this complaint. LPA met with Resident Care Coordinator, Veronica Guinea (RCC), announced who he is and the reason for the visit was it issue final findings to the allegations to this complaint.

As to the allegation of, “Facility did not answer residents call button in a timely manner.” It was alleged that the facility staff took 30 to 45 minutes to answer Resident 1 (R1’s) call button. It was discovered through documentation that, on 04/03/2025 there was a subsequent substantiated complaint pertinent to the facility call system being down from 03/28/2025 through 04/07/2025 that was filed. On 07/30/2025, LPA Jeffries reviewed the call button history for the room that R1 had resided.

CONTINUED on LIC-9099-C .
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
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 5
Control Number 29-AS-20250624093140
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: 08/01/2025
NARRATIVE
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The “Resident Incident Details Report” that was provided by facility, which shows 20 calls from R1’s room, dating from 04/13/2025 through 05/07/2025. 14 of 20 calls showed a response time ranging from approximately 11 minutes and 22 seconds (11:22) to 1 hour 49 minutes and 46 seconds (1:49:46) resulting in late responses average of approximately 41 minutes per late call, of the 14 late calls. And 1 minute and 35 seconds (1:35) average per the 6 acceptable call response times. At this time there is sufficient evidence to support the allegation of, “Facility did not answer residents call button in a timely manner.” and is substantiated at this time.

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

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20250624093140
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: 08/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet residents’ needs. … This requirement was not met by the number of call response that resulting in call button times exceeding 41
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PCC stated staff numbers are increased and all staff now has a walk-eTalke. PCC agrees to have a all staff training on call button response times, and clearing all calls in a timely manor. PCC will provide proof of training to LPA by 08/13/2025.
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minutes, which poses a potential 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: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
06/24/2025 and conducted by Evaluator Mark Jeffries
COMPLAINT CONTROL NUMBER: 29-AS-20250624093140

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: 54DATE:
08/01/2025
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Intern Administrator, Sarah KauTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Facility did not ensure residents’ care needs were met.
Staff violated residents’ personal rights.
Facility was not maintained sanitary.
INVESTIGATION FINDINGS:
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 As to the allegation of, “Facility did not ensure residents’ care needs were met.” It was alleged that, prior to 05/15/2025, Resident 1 (R1) was not assisted with brushing teeth and toileting. It was discovered through interviews and documentation that on 06/26/2025, LPA Jeffries conducted staff interviews of Staff 1-3 (S1, S2, and S3) all who work in the Memory Care Unit. S1, S2 and S3, all stated, staffing for memory care is good enough, residents are checked for incontinence issues throughout the shift and as needed. On 06/28/2025, LPA Jeffries reviewed R1’s Needs and Services Plan dated 04/17/2025, which indicated R1 required “Standby Assist” “Resident is able to manage own toileting needs, Resident may be fatigued and require assistance with brief charges for safety. On 04/25/2025 and 05/06/2025, R1’s Needs and Services Plan changed to “Total Assist” for toileting care, which indicates that facility was monitoring R1’s ability for self care during the months of April and May of 2025. LPA Jeffries reviewed documentation of R1’s Home Health Care Provider, Outside Agency/Services Documentation form, showing 7 Home Health visits for R1 during the time period of 05/01/2025 through 05/13/2025 which showed, no concerns under the
CONTINUED on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20250624093140
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: 08/01/2025
NARRATIVE
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 “Identified concerns and recommended actions take to resolve” entry to that form. LPA also noted that Outside Agency Service and Documentation form showed 52 prior visits without any additional concerns for R1 prior to the month of May 2025. Based on interviews, and documentation, there is not enough evidence to support the allegation of, “Facility did not ensure residents’ care needs were met.” and is unsubstantiated at this time.
As to the allegation of, “Staff violated residents’ personal rights.” It was alleged that on 04/17/2025, R1 was not allowed to go to bedroom from the activity room. It was discovered through interviews and documentation that, on 06/26/2025, LPA Jeffries conducted an interview with S1, S2, and S3, all who stated that another Resident (R2) in Memory Care attempted to push R1 in their wheelchair into R1’s Room. All 3 staff stated that R1 and R2 were redirected back to the activity room for the safety of both residents. All 3 staff denied not allowing access to R1 to their room at any time other than R2 going into R1’s room for safety concerns. LPA Jeffries reviewed the staff schedule for 04/17/2025 and confirmed that S1, S2, and S3 were working in memory care on 04/17/2025. LPA Jeffries reviewed training for S1. S2, and S3 and all staff were current in the required staff training hours. R1 was no longer a resident at the facility and could not be interviewed. On 06/26/2025 LPA Jeffries attempted to interview R2, however R2 was not able to answer questions about 04/17/2025. At this time there is not enough evidence to support the allegation of, “Staff violated residents’ personal rights.” and is unsubstantiated at this time.
As to the allegation of, “Facility was not maintained sanitary.” It was alleged that staff did not clean R1’s room or make R1’s bed, when wet with urine and floor had dried urine. It was discovered through interviews, documentation and observations that on 06/26/2025, LPA Jeffries conducted a physical inspection of the facility with focus on Memory Care Unit and room that R1 had resided over a month past. LPA noted that there were two housekeepers working in memory care unit and there were no overt smells and the facility and memory care appeared clean and in good repair. LPA noted that R1s former room was clean, floors were clean and discovered no issues in R1 former room. On 07/10/2025, 07/14/2025, and 07/22/2025, LPA conducted a physical walk through of the facility including memory care unit. LPA noted that the facility was clean and in good repair and noted at least two or more housekeeping staff working to clean rooms during these visits. LPA reviewed the facility schedule and noted that housekeepers were consistently scheduled during the months of April and May of 2025, additionally Care Staff was also consistently scheduled during April and May of 2025. Based on observations, and documentation there is not enough evidence to support the allegation of, “Facility was not maintained sanitary.” and is unsubstantiated at this time.
Exit interview, report read, appeal rights and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE:

DATE: 07/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5