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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608598
Report Date: 02/22/2023
Date Signed: 02/22/2023 11:04:01 AM

Document Has Been Signed on 02/22/2023 11:04 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:MONICA VARTANIANFACILITY TYPE:
735
ADDRESS:44333 STADIUM COURTTELEPHONE:
(661) 674-8592
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
02/22/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Marybeth Chavez, CaregiverTIME COMPLETED:
11:20 AM
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On 2/22/22 at 9:50am, Licensing Program Analyst (LPA) Shira Stamps conducted an unannounced one (1) year required visit for this facility. LPA informed the Administrator over the phone of the purpose of the visit. The Administrator was currently in training and unable to go to the facility. She designated staff member Marybeth Chavez to sign the report.

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 caregiver and sanitizer was available.

A tour of the physical plant was conducted with the caregiver at 10:00 am. The facility has five (5) bedrooms, with one (1) room designated for live in staff, and two (2) bathrooms currently occupying four (4) clients.

Food Inspection
LPA conducted a tour of the kitchen around 10:05 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 double locked and inaccessible to clients in care. At 10:07 am LPA observed medications to be locked and inaccessible to clients.

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

Continued....

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2023
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: 02/22/2023
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Bathrooms
At 10:15 am LPA observed all bathrooms to have non-skid matts, grab bar. Hot water was tested and measured within regulation at 117.8°F.

Laundry


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

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 72°F. The dual smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:25 am. There is one (1) fire extinguisher, located in the kitchen. Fire extinguisher was observed to be full but last serviced in 01/03/2023. Staff and resident files were observed to be locked and inaccessible to clients.

Physical environment
LPA toured the outside area of the facility at 10:26 am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There is no body of water on the premises.

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

Administrative: The facility is currently on a non-compliance plan. LPA has received and reviewed the required training for each month. LPA observed heat related signs posted throughout the facility. The signs included instruction on what to look for, signs and symptoms.

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: 02/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2023
LIC809 (FAS) - (06/04)
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