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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850365
Report Date: 11/06/2025
Date Signed: 11/06/2025 04:45:23 PM

Document Has Been Signed on 11/06/2025 04:45 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:		MORGAN WILLIAMSFACILITY TYPE:
740
ADDRESS:1420 W NORTH AVENUETELEPHONE:
(805) 736-1234
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 130CENSUS: 50DATE:
11/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Community Rekations, Sarah KauTIME VISIT/
INSPECTION COMPLETED:
05:10 PM
NARRATIVE
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 At 9:00am on 11/06/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. Additionally, LPA issued final findings to the allegations to a separate complaint on a separate report. LPA met with Community Relations Director, Sarah Kau (CRD), LPA announced who he is and the reason for this visit. CRD made phone contact with Administrator Morgan Williams who was unavailable for annual inspection, who provided verbal authorization for CRD to sing for annual inspection report and compliant findings.
This facility is approved for a maximum capacity of one hundred thirty (130) residents. All residents licensed and approved for non-ambulatory status, of which ten (10) may be bedridden. Facility is approved for delayed egress, with an approved hospice care waiver for twenty (20) residents. This facility has a main kitchen for all residents of the facility, and two (2) dining rooms. One (1) dining room is specifically for the Assisted Living residents of the facility, and the other dining room is for the Memory Care residents of the facility. CRD and LPA conducted physical inspection facility grounds outside, in-closed courtyards and building including resident rooms, storage, kitchen, dining rooms, medication room and offices. LPA observed at least 2 days of perishable food and at least 7 days of non-perishable food items maintained in the facility and sufficient emergency water supply located in the facility kitchen. LPA noted that resident rooms all have on suit bathroom. All resident rooms had required furniture and linins per regulations. LPA observed facility Maintenance Supervisor tested water in resident memory care bedroom that exceeded regulation standards of 120*(f), citation was issued [87303(e)(2)]. LPA observed chemicals stored in unlocked cabinet in memory care unit, citation issued [87309(a)]. LPA observed door to facility kitchen not operating properly and not closing as designed, and courtyard fountain in disrepair with loose rocks in the walkway surround fountain, citation issued [87303(a)]. No other citations or violations noted during the physical inspection of the facility. CONTINUED on LIC9099-C
NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Mark Jeffries
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2025
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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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: 11/06/2025
NARRATIVE
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LPA observed fire extinguishers lactated throughout the facility all primed and in the green indicating working. LPA reviewed annual fire inspection dated 07/14/2025 from Securitas Fire Systems showing visual and functional test of sprinkler fire system with a grade of passing. LPA noted that there are complete first aide kits in memory care, kitchen and medication room. LPA noted that all hallways, sliding doors, doors and passageways were free and clear of debit.

CRD and LPA conducted a full review of the annual care tools. LPA reviewed Emergency Disaster Plan, Infection Control Plan, Liability Insurance, and Centrally Stored Medication Records. LPA reviewed a sample of Staff and Resident files. LPA noted that there were no other violations or citations issued as a result of the document and file reviews. LPA noted no other citations or violations as a result of this annual facility inspection.

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

DATE: 11/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 04:45 PM - It Cannot Be Edited


Created By: Mark Jeffries On 11/06/2025 at 02:55 PM
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: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of facility kitchen door that leads to resident hallway and disrepair of fountain in in-closed courtyard with rocks on pathway, the licensee did not comply with the section cited above in 2 out of 2 observations of disrepair, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2025
Plan of Correction
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Community Relations Director agrees to repair kitchen door leading to resident hallway and midigate the disrepair of the fountain and immidated fountian area by 11/20/2025. CRD will provide photographic and/or video evidence to LPA by cell phone no later than 11/20/2025.
Section Cited
Deficient Practice Statement
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POC Due Date: 11/20/2025
Plan of Correction
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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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 04:45 PM - It Cannot Be Edited


Created By: Mark Jeffries On 11/06/2025 at 03:00 PM
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: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in that the water temperature in residetn room exceeded 120*(f), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2025
Plan of Correction
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During inpsection facility Maintenance Director made temperture adjustments to hot water heaters and conducted additional water test througout the facility. CRD will email LPA updates on 11/13/2025 and 11/20/2025 of regulated water temperture checks that show complaince of maininting a facility water temperature of 105*(f) -120*(f).
Section Cited
Deficient Practice Statement
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POC Due Date: 11/20/2025
Plan of Correction
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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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/06/2025 04:45 PM - It Cannot Be Edited


Created By: Mark Jeffries On 11/06/2025 at 04:32 PM
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: 11/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 11/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2025


LIC809 (FAS) - (06/04)
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