197608598-1-19-2022-31-AS-SSTS-CATNLD-20220119093321

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608598
Report Date: 01/11/2022
Date Signed: 01/19/2022 09:34:12 AM

Document Has Been Signed on 01/19/2022 09:34 AM - 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MOLOCK RESIDENTIAL INC.		FACILITY NUMBER:	197608598
ADMINISTRATOR:	JONATHAN ALLEN MOLOCK		FACILITY TYPE:	735
ADDRESS:	44333 STADIUM COURT		TELEPHONE:	(661) 674-8592
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 3	DATE:	01/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:38 AM
MET WITH:	Monica Vartanian, Administrator		TIME COMPLETED:	01:15 PM

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On 1/11/22 at 11:38am, Licensing Program Analyst (LPA) Shira Stamps met with Administrator Monica Vartanian for an unannounced one (1) year required visit for this facility.

LPA arrived at 11:38 am and was greeted by the Administrator. Two (2) residents were observed to be in the living room watching TV. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed facility mitigation plan (approved on 01/30/21) to make sure the Administrator was following current infection control recommendations. Upon arrival LPA was screened by the Administrator and was asked infection control question. The Administrator signed LPA in and sanitizer was available.

A tour of the physical plant was conducted with the Caregiver, Sambria Peralta at 11:40 am. The facility has five (5) bedrooms, with one (1) room for staff, and two (2) bathrooms currently occupying three (3) residents. The facility is Fire Cleared for six (6) ambulatory.

Resident Rooms
LPA observed all rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each bedroom.

Bathrooms
At 11:50 am LPA observed all bathrooms to have non-skid matts, grab bars, and paper towels. Hot water was tested at 11:56 am and measured within regulation at 117.4°F.

Continued....

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

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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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOLOCK RESIDENTIAL INC.	FACILITY NUMBER: 197608598
	VISIT DATE: 01/11/2022

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Laundry
LPA observed chemicals/hazardous items to be located in the locked hallway closet. The Laundry room appeared to be neat and clean.

Food Inspection
LPA conducted a tour of the kitchen around 11:45 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to residents in care. At 11:47 am LPA observed medications to be locked and inaccessible to residents.

Physical environment
LPA toured the outside area of the facility at 11:57 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is no body of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:30 pm. There is one (1) fire extinguisher, located in the kitchen. Fire extinguisher was observed to be full but last serviced in 05/2017. LPA reviewed the facility history and observed the last annual stated the fire extinguisher was full, but no service date was provided and no deficiency cited. At 11:57 am, LPA observed Administrator to set an appointment for the fire extinguisher to be serviced on 1/14/22. The Administrator stated she will provide verification to LPA once it has been serviced. Staff and resident files were observed to be locked and inaccessible to residents.

Garage
LPA observed the garage to be attached to the facility. Extra food is stored in the deep freezer and the second refrigerator.

Administrative: Annual fee is current. An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 01/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022

LIC809 (FAS) - (06/04)

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