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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609337
Report Date: 11/09/2023
Date Signed: 11/09/2023 03:52:01 PM

Document Has Been Signed on 11/09/2023 03:52 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 IIFACILITY NUMBER:
197609337
ADMINISTRATOR:MONICA VARTANIANFACILITY TYPE:
735
ADDRESS:43140 E 33RD STREETTELEPHONE:
(661) 674-8592
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 3DATE:
11/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monica VartanianTIME COMPLETED:
02:15 PM
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Licensing Program Analysts (LPAs) Lorena Casillas and Melissa Spaeth 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.

LPAs arrived at 10:00 am. There was no one in the facility. LPA Casillas called Administrator and was told that staff would meet with us in about 20 minutes. LPAs were met by staff member Maria Esquivel. Administrator arrived shortly after. LPAs informed the Administrator of the purpose of the visit. All clients were in their day programs. Entrance interview conducted.

A tour of the physical plant was conducted with the Administrator at 10:50 am. The facility has five (5) bedrooms and two (2) bathrooms. It is currently occupied by three (3) clients. One (1) bedroom is designated for staff use only.

Infection control: LPAs reviewed facility mitigation plan (approved on 01/30/21) to make sure licensee was following current infection control recommendations.

Food Inspection
LPAs conducted tour of the kitchen around 10:50 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPAs observed chemicals, all knives, and sharp objects in the locked kitchen cabinet under the sink. LPAs observed the medications cabinet locked, along with the first aid kits.

CONTINUED.....
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/09/2023
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MOLOCK RESIDENTIAL II
FACILITY NUMBER: 197609337
VISIT DATE: 11/09/2023
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Living and dining
LPAs observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. LPAs 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 11:00 am. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 01/03/2023.

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

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

Bathrooms
LPAs observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. Hot water was tested at 1:02 pm and measured within regulation at 115.5 degrees F.

Garage
At 11:05 am, LPAs observed the garage to be attached to the facility and currently being used for extra storage, PPE supplies, a refrigerator and small deep freezer.

Physical environment
LPAs toured the outside area of the facility at 11:15 am. LPAs observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Administrative: LPAs collected the LIC.500 and resident roster. Annual fees are current.

Resident Files:


LPAs conducted a file review of resident records to ensure compliance of licensing forms at 11:30am.

CONTINUED....
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
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 II
FACILITY NUMBER: 197609337
VISIT DATE: 11/09/2023
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Staff Files:
LPAs conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 12:00 pm.

Medications:
At 12:30 pm LPAs and staff reviewed medication and medication records for proper documentation.

No citations were issued. An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023
LIC809 (FAS) - (06/04)
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