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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609337
Report Date: 08/08/2022
Date Signed: 08/08/2022 03:07:52 PM

Document Has Been Signed on 08/08/2022 03:07 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MOLOCK RESIDENTIAL IIFACILITY NUMBER:
197609337
ADMINISTRATOR:MONICA VARTANIANFACILITY TYPE:
735
ADDRESS:43140 E 33RD STREETTELEPHONE:
(661) 674-8592
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 3DATE:
08/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Monica Vartanian, Administrator TIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Monica Vartanian for an unannounced one (1) year Required visit for this facility. The facility is currently on a non-compliance plan and the focus for today’s visit is training for staff.

LPA arrived at 1:30 pm and was greeted by staff member Brenda Williams (Rodriguez). LPA informed the Administrator of the purpose of the visit. All clients were in their day programs or out in the community. Entrance interview conducted.

A tour of the physical plant was conducted with the Administrator at 1:55 pm. The facility has five (5) bedrooms and two (2) bathrooms currently occupying three (3) clients. One (1) bedroom is designated for staff use only.

Infection control: LPA reviewed the facility mitigation plan (approved on 01/30/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by staff member and asked all infection control questions. LPA signed-in and sanitize/wash hands was available.

Food Inspection
LPA conducted tour of the kitchen around 1:55 pm 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 care clean and inaccessible to pests. LPA observed chemicals, all knives and sharp objects in the locked kitchen cabinet under the sink. LPA observed the medications cabinet locked, along with the first aid kits.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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 II
FACILITY NUMBER: 197609337
VISIT DATE: 08/08/2022
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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. LPA observed staff and client files locked in the filing cabinet. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 2:13 pm. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 01/14/22.

Laundry
LPA observed the laundry, and no chemicals or hazardous materials are stored there.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client. LPA observed cleaning supplies/chemicals in the locked hallway closet.

Bathrooms
LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 2:10 pm and measured within regulation at 112.5 degrees F.

Garage
At 2:10 pm, LPA observed the garage to be attached to the facility and currently being used extra storage, PPE supply (60days supply), and an refrigerator and small deep freezer.

Physical environment
LPA toured the outside area of the facility at 2:15pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

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

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
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 II
FACILITY NUMBER: 197609337
VISIT DATE: 08/08/2022
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Administrative: LPA collected the LIC.500 and resident roster. Annual fees are current.

Record Review: LPA reviewed the following training records: Consumer rights (6/6/22), Health Chemical Training (6/2/22), Weather Policy (5/27/22), P&I NLACRC (4/27/22), infection control plan (6/29/22), and the POC training for the non-compliance plan which included the following: Personal requirements, Administrator Qualifications, Culture of Compliance, Responsibility of care and supervision, and Heat Exhaustion.

An exit interview was conducted and copy of this report was given for the Administrator.

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

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC809 (FAS) - (06/04)
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