FOUNTAIN SQUARE OF LOMPOC

Official classification

Type B

Official code

87405(a)

Regulation authority

CCR

What the official deficiency says

87405Administrator - Qualifications and Duties (a)All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other administration of the facility as responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated specifiedsection.

Official plan of correction

substitute who shall have qualifications adequate to be responsible and accountable for management and in this The Department may require that the administrator devote additional hours in the facility ... This requirment is not met be evidence of the lack of assigned Administrator and posess a potential risk to residents in care. BOM agrees to contact Parent Company (Tharon Lompoc, LLC) and provied weekly updates to the LPA as to the assingment of new Administrator, and cordinate all open Plan of Corrections with parent company untill all POC are cleared.

Deadline recorded: Sep 3, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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 more than 10 minute response times as indicated in the complaint, which poses a potential danger to residents in care.

Official plan of correction

Administrator agrees to conduct a training will all staff on address call button calls, how recongnuze and write a procedue for staff to recognize, address, and clear call button calls in the facility. To be completed by 06/29/2025 and email LPA documentation.

Deadline recorded: Jun 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87465

Regulation authority

CCR

What the official deficiency says

(a) A plan for incidental medical .. each facility. The plan shall encourage routine medical …such care, by compliance with the following: (6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met by evidence of facility documentation failing to record dosage of medication provided on 03/16/2026 which poses a potential danger to residents in care.

Official plan of correction

Administrator agrees to have all medication technitions to complete a 1 hour additional training on documentation of medication. To be completed by 06/29/2025 and email LPA documentation.

Deadline recorded: Jun 29, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(14)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)… Personal Rights of Residents in All Facilities, residents… shall have all of the following personal rights: (14) To reasonable accommodation of their individual needs and preferences in all the health or aspects of life in the facility, except when accommodation would endanger safety of the individual resident or other residents. This requirement was not met by evidence of multipal prolonged times staff answering R1’s call buttons, which poses an imminent risk to residents in care.

Official plan of correction

Community Relations Director (CRD), agreed to conduct Personal RIghts training for all staff on All Staff meeting. CRD will notifiy LPA of specific personal rights training course and date when all staff will complete training by 11/07/2025.

Deadline recorded: Nov 7, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 11/20/2025 Plan of Correction 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.

Official classification

Type B

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 11/20/2025 Plan of Correction 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).

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: Plan of Correction

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

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 minutes, which poses a potential risk to residents in care.

Official plan of correction

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.

Deadline recorded: Aug 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that ... 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 was not met by evidence of: The licensee did not follow the section cited above when S1 brought a loaded gun into the facility and left it accessible, which posed an immediate health and safety risk to residents in care.

Official plan of correction

Administrator agrees to conduct an all staff meeting to review employee handbook section that specificity address weapons at work. Administrator agreed to the all staff meeting that is taking place on 07/22/2025, and Administrator will send All Staff agenda signatures of staff in attendance to LPA.

Deadline recorded: Jul 22, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

Administrator agrees to reevalute and update medication securty policy and send update to LPA by 07/11/2025.

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(2)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

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.

Deadline recorded: Jul 24, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87218(a)(2)

Regulation authority

CCR

What the official deficiency says

87218 Theft and Loss (a) The licensee shall ensure an adequate theft and loss program...(2) A licensee who fails to make reasonable efforts to safeguard resident property,... The licensee shall be presumed to have made reasonable efforts to safeguard resident property if there is clear and convincing evidence of efforts to meet each requirement specified in Section 1569.153. This requirement was not met by evidence of lack of screening of uncleared staff and vendors, which puts residents in potential danger.

Official plan of correction

Administrator will start the recruting and hiering process for a front desk receptionist to help with screening residents, vendors, and visitors.

Deadline recorded: Jun 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87468.2(a)(25)

Regulation authority

CCR

What the official deficiency says

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (25) To protection of their property from theft or loss according to Health and Safety Code ... This requirement was not met by evidence of several missing property items of Resident 1, which poses a potential risk to residents in care.

Official plan of correction

Administrator argrees to have a one hour training for all staff on personal rights and safeguarding residents property and information.

Deadline recorded: Jun 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87464(d)

Regulation authority

CCR

What the official deficiency says

Basic Services (d)...if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal…and providing the other basic services…either directly or through outside resources. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. Staff did not provide adequate care and supervision, residents sustaining falls resulting in injuries...

Official plan of correction

Licensee has hired additional staffing. Adminstrator will train staff on identifying changes in condition and communicating this to leadship to update resident appraisals. Administrator will email LPA the date of this training by 5/31/2025 and the completed training and signed roster after completed. which posed an immediate health and safety risk to residents in care.

Deadline recorded: May 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

Additional Personal Rights of Residents in Privately Operated Facilities (a) .., residents... shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers...to meet their needs. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above when they did not provide adequate staffing which resulted in residents needs not being met, including residents being left soiled for an extended period of time.

Official plan of correction

Licensee has hired additional staffing. Adminstrator will train staff on identifying changes in condition and communicating this to leadship to update resident appraisals. Administrator will email LPA the date of this training by 5/31/2025 and the completed training and signed roster after completed.

Deadline recorded: May 31, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(B)

Regulation authority

CCR

What the official deficiency says

Reporting Requirements(a) ... (1) A written report shall be submitted to the licensing agency…within seven days of the occurrence of any of the events specified in (A) through (D) below.... (B) Any serious injury as determined by the attending physician and occurring while... the resident is under facility supervision. This requirement is not met as evidenced by: Based on interviews and records review, the licensee did not comply with the section cited above. The Licensee did not submit incident reports for numerous falls for R1 and R4,...

Official plan of correction

Administrator agrees to update their reporting protocol and conduct a staff training of the protocol. Administrator will email LPA documentation and a signed staff roster off all training participants on or before 6/13/2025. the resident is under facility supervision.

Deadline recorded: Jun 13, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(i)(1)(C)

Regulation authority

CCR

What the official deficiency says

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 evidence of Administrator admitting and reporting signal system malfunction. Which poses a potential risk to resident in care

Official plan of correction

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.

Deadline recorded: Apr 17, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report submitted to licensing agency…within seven days...(D) Any incident that threatens welfare, safety or health of any resident This requirement was not met based on interviews and record review; licensee did not comply with section cited above when Licensing Department did not receive incident reports regarding a resident fall and physical altercation which posed a potential health and safety risk to residents in care.

Official plan of correction

Licensee agrees to submit Incident Reports to the Licensing Agency regarding any incident that threatens the welfare, safety, or health of any resident. The licensee will submit a plan describing how the facility will ensure reporting requirements are followed.

Deadline recorded: Dec 5, 2024. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.2(a)(4)

Regulation authority

CCR

What the official deficiency says

87468.2(a)(4) Add’tl Personal Rights of Residents…(a) …residents in...RCFE shall have all following personal rights: (4) To care, supervision, and services that meet individual needs delivered by staff sufficient in numbers, qualifications, and competency to meet needs. This requirement is not met based on interviews and record review, licensee did not comply with the section cited above when staff failed to provide appropriate supervision to Resident #1 resulting in multiple incidents which posed an immediate health and safety risk to residents in care.

Official plan of correction

The licensee will take appropriate measures to maintain and increase staffing in the facility. Licensee will also provide training to all staff on resident personal rights including supervision and neglect.

Deadline recorded: Nov 8, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

87411(a) Personnel Requirements-General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... to ensure provision of personal assistance and care This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to have sufficient staff to meet the needs of residents, which posed a potential health and safety risk to residents in care.

Official plan of correction

The licensee has shown LPA appropriate measures to maintain and increase staffing in the facility, including job advertisements observed by the LPA.

Deadline recorded: Oct 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

87211(a)(1)(D) Reporting Reqs. Licensee shall furnish to licensing agency...including...(1) Written report submitted to licensing agency and to person responsible for resident within 7 days… (D) Any incident which threatens the welfare, safety or health of any resident… This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with section cited above by failing to report an incident and change of condition in R1 to licensing and responsible pary, which posed a potential health and safety risk to residents in care.

Official plan of correction

The licensee has submittted a plan describing how the facility will ensure reporting requirements are followed. Submit proof to Community Care Licensing Division (CCLD).

Deadline recorded: Oct 1, 2024. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87211(a)(1)(A)

Regulation authority

CCR

What the official deficiency says

87211a(1)(A),(B) Reporting Reqs. Licensee shall furnish to licensing agency...including...(1) Written report to licensing agency…within 7 days…(A) Death of resident...regardless where death occurred...(B) Any serious injury determined by attending physician..occurring to resident under facility supervision This requirement is not met as evidenced by: Based on interviews and records review, licensee did not comply with the section cited above. Licensee did not submit incident reports for R1's hospitalizations or death report for R1, which posed a potential health and safety risk to residents in care.

Official plan of correction

The licensee will submit a plan describing how the facility will ensure reporting requirements are followed. Submit proof to Community Care Licensing Division (CCLD) by 08/08/2024

Deadline recorded: Aug 8, 2024. A deadline is not proof that correction was completed.