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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608598
Report Date: 06/02/2022
Date Signed: 06/02/2022 11:02:44 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., 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:4CENSUS: 4DATE:
06/02/2022
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Monica Vartanian, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Client sustained severe sunburns while in care
INVESTIGATION FINDINGS:
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On 6/2/22, Licensing Program Analyst (LPA) Shira Stamps conducted an unannounced subsequent visit to deliver the findings regarding the allegation, “Client sustained severe sunburns while in care.” LPA was greeted by the caregiver, and the Administrator Monica Vartanian arrived shortly after. LPA explained the purpose of the visit. Entrance interview conducted.

On 10/01/21, a complaint was received by the Woodland Hills Adult and Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s, Investigations Branch (IB). The allegation, “Resident sustained severe sunburns while in care”, was accepted by IB and assigned to Investigator Brian Slatic.

On 10/04/21 LPA Shira Stamps and Melissa Ruiz initiated the complaint. LPA’s conducted a physical plant tour and requested documentation relevant to the complaint. CONTINUED...


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

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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: 06/02/2022
NARRATIVE
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The investigator initiated interviews with clients, staff, and other witnesses on 10/26/21; 12/27/21, and 01/10/22. Hospital medical records were subpoenaed on October 4, 2021, received 10/08/2021 and reviewed on 10/19/2021. Client and personnel records review were conducted on 3/30/22.

The investigation revealed that on August 29, 2021, C1 was sitting outside in the backyard for approximately 45 minutes in 105 degree weather without constant supervision. Eventually when staff checked on C1, C1 was observed to be sweaty, and less responsive. The client could not move from the seat therefore, was lowered to the grass. The paramedics were contacted and C1 was taken to the hospital for care. C1 was diagnosed with dehydration, heat exposure and received wound care treatment for significant right and left foot burns that were described as “acute Full thickness Burns” which resulted in debridement on a total of 5 wounds. Home health skilled nursing services were initiated to tend to the wounds.

Per records review of C1’s Individual Program Plan (IPP), C1 needs constant daily supervision in all settings to prevent harm or injury. In addition, the Administrator did not provide staff appropriate training related to heat exhaustion.

Therefore, after review of the information gathered the allegation, “Client sustained severe sunburns while in care,” is substantiated. A civil penalty shall be issued for a violation that resulted in an injury to a client in care.

Exit interview conducted. Civil Penalties issued, report and appeal rights delivered to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited
CCR
80065(e)
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80065(e) Personnel Requirements
The licensee shall provide for direct supervision of clients during participation in or presence at potentially dangerous activities or areas in the facility.

This requirement was not met as evidence by:
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The Administrator will need to implement a detailed policy/procedure related to identifying heat exhaustion. The plan would need to demonstrate the process to identify heat exhaustion, and how to meet the needs of the client.
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Based on interviews and information obtained during the course of the Investigation Branch’s (IB) investigation the Licensee did not provide proper care and supervision to meet the needs of the clients by leaving the client outside in the heat resulting in
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 C1 sustaining serious bodily injury which poses an immediate health and safety and personal rights risks to clients in care. Immediate civil penalty in the amount of $500.00 is issued on this day for a violation which resulted in injury to C1.
Type A
06/03/2022
Section Cited
ILS
80064(7)
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80064(7) Administrator-Qualifications and Duties
Ability to recruit, employ, train, and evaluate qualified staff, and to terminate employment of staff, if applicable to the facility.

This requirement was not met as evidence by:
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On 8/30/21 The Administrator conducted an emergency training related to heat exhaustion. The Administrator stated they will provide another training related to heat exhaustion for the upcoming summer months, and will submit the training material and signatures of all staff that have completed the training.
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Based on interviews and document review the Administrator did not provide training proper training related to heat exhaustion resulting in serious bodily injury to C1 which poses an immediate health and safety and personal rights risks to clients 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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022
LIC9099 (FAS) - (06/04)
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