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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608598
Report Date: 01/12/2024
Date Signed: 01/12/2024 12:30:27 PM


Document Has Been Signed on 01/12/2024 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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: 3DATE:
01/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monica VartanianTIME COMPLETED:
12:45 PM
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On 01/12/2024 at 10:00 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced one (1) year required visit for this facility. The facility is currently on a 2 year non-compliance plan. LPA informed the Administrator 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.

A tour of the physical plant was conducted with the Administrator at 10:15 am. The facility has five (5) bedrooms, with one (1) room designated for live in staff, and two (2) bathrooms currently occupying three (3) clients. Two (2) clients were observed in the living area watching TV and one (1) client was in day program.

Food Inspection: LPA conducted a tour of the kitchen around 10:15 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. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects being double locked and inaccessible to clients in care. At 10:17 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, chair, and sufficient lighting for each bedroom.

Bathrooms: At 10:25 am LPA observed all bathrooms to have non-skid matts, grab bar. Hot water was tested and measured within regulation at 116.9°F.

Continue on 809C
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOLOCK RESIDENTIAL INC.
FACILITY NUMBER: 197608598
VISIT DATE: 01/12/2024
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Laundry: LPA observed chemicals/hazardous items locked in the 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 and last serviced in 01/03/2023, per Administrator, Fletchers Fire Protection Services will be in the home today 01/12/24 to service the extinguisher.

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.

Administrative: LPA has received and reviewed the required training for each month. LPA observed heat related signs posted throughout the facility. The signs included instructions on what to look for, signs and symptoms.

Staff Interviews: At 11:05 am LPA interviewed staff.



Client Interviews: At 11:20 am LPA attempted interviews with clients.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms at 11:25 am.

Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 11:50 am.

Medications: At 12:00 pm LPA and Administrator reviewed medication and medication records for proper documentation.

An exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Lorena CasillasTELEPHONE: 818-304-2695
LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2024
LIC809 (FAS) - (06/04)
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