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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608598
Report Date: 10/28/2021
Date Signed: 10/28/2021 03:47:08 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., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2021 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20211001095506
FACILITY NAME:MOLOCK RESIDENTIAL INC.FACILITY NUMBER:
197608598
ADMINISTRATOR:JONATHAN ALLEN MOLOCKFACILITY TYPE:
735
ADDRESS:44333 STADIUM COURTTELEPHONE:
(661) 674-8592
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:6CENSUS: 4DATE:
10/28/2021
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Monica Vartanian, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Client did not consume the appropriate amount of liquids while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shira Stamps and Melissa Spaeth conducted an unannounced subsequent complaint visit to interview staff and residents regarding the allegation, ‘Client did not consume the appropriate amount of liquids while in care.’

LPAs arrived at 10:05am and were greeted by caregiver Michelle Buenaventra. Administrator Monica Vartanian arrived at 10:24am. At approximately 10:45 am, LPA’s began reviewing documents that consisted of but not limited to client’s physician reports, Individualized Personal Plans (IPP’s), staff incident logs, staff training, and the facility food menu.



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
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 31-AS-20211001095506
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOLOCK RESIDENTIAL INC.
FACILITY NUMBER: 197608598
VISIT DATE: 10/28/2021
NARRATIVE
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LPAs conducted a physical plant tour at 11:45am, and LPAs did not observe any immediate health and safety risks during this visit. LPAs began interviewing residents and staff members at 10:55am. LPAs interviewed the Administrator, three (3) staff members and three (3) residents, two (2) of which residents are non-verbal.

Allegations: Client did not consume the appropriate amount of liquids while in care.

Based upon interviews with staff (S1) and Administrator, Staff member (S2) did not promptly respond to the care of the resident. S1 stated C1 was found unresponsive in the backyard sitting in a chair located in the sun. It was reported to CCL that S2 left C1 in the sun for forty-five minutes. Staff members S1 and S2 attempted to transport C1 back into the facility, but were unable to assist. Paramedics were called, and C1 was given first aid by fluid, oxygen, and ice. It was observed by staff members and the Administrator, the day after the incident occurred, blisters appeared on C1's feet, and C1 was taken back to the doctor for treatment. Based upon medical records from Antelope Valley hospital, C1 was dehydrated.

Therefore the allegations, ‘Client did not consume the appropriate amount of liquids while in care,’ is Substantiated. Under Title 22 General Regulations, the following citation was issued and recorded on LIC 809D.


Exit interview conducted. Appeal Rights discussed and report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20211001095506
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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOLOCK RESIDENTIAL INC.
FACILITY NUMBER: 197608598
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2021
Section Cited
CCR
80078(a)
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The licensee shall provide care and supervision as necessary to meet the client's needs.
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As of 8/30/21, Administrator conducted an emergency training session with staff and explained the importance of hydration of residents.

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This was not met based upon: Based upon interviews with staff and Administrator, Staff did not promptly respond to the care of the resident. Thus, resulting in resident's hospitalization and diagnosis of dehydration.
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At 10:30am and 11:30am LPA Stamps and Spaeth observed staff providing residents with water; therefore the staff has implemented the heat related and hydration training.
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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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3