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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609337
Report Date: 01/03/2024
Date Signed: 01/03/2024 12:03:43 PM

Document Has Been Signed on 01/03/2024 12:03 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: 4DATE:
01/03/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monica VartanianTIME COMPLETED:
12:15 PM
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On 01/03/2024 Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility above to conduct a Case Management - Legal/Non-compliance visit and inspection of the facility to ensure facility compliance. LPA met with Administrator Monica Vartanian and explained the reason for the visit. On 06/15/2022, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional office. As a result of that NCC, the facility was placed on a two year compliance plan.

Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility above at 10:00 am. There was no one in the home, LPA called Administrator and was told that someone would arrive shortly. At 10:20 am staff member Brenda Williams (Rodriguez) arrived to allow entry to the facility. The Administrator, Monica Vartanian, arrived at 10:30 am. LPA explained the purpose of this visit. Entrance interview conducted with the Administrator.

Administrator informed LPA that all clients were currently in their day programs.

At approximately 10:40 a.m., LPA and administrator took a tour of the physical plant.

Today’s focus was infection control, training for staff, and sufficient staffing for supervision.

LPA conducted a physical plant tour and observed the facility maintains a comfortable temperature of 72°F. LPA also observed heat/weather related signs posted throughout the facility. Water temperature was tested and measured at 119.8 F. LPA observed new patio furniture added to back yard. LPA observed sufficient water supply for all clients.

LPA reviewed the LIC500 (Personnel Report) and found there to be sufficient staff for each shift. LPA also reviewed the staff training files regarding heat related training and care and supervision. LPA verified that all staff have completed this training.

Continued...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2024
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 II
FACILITY NUMBER: 197609337
VISIT DATE: 01/03/2024
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LPA collected training documents regarding care and supervision and heat related training. LPA collected LIC500, Client roster, Administrator Certificate, and Infection Control Plan.

Exit interview conducted. A copy of this report is signed and delivered to Administrator.

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

DATE: 01/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024
LIC809 (FAS) - (06/04)
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