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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610586
Report Date: 08/28/2024
Date Signed: 08/28/2024 11:28:08 AM

Document Has Been Signed on 08/28/2024 11:28 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PETRA RESIDENTIAL INC.FACILITY NUMBER:
197610586
ADMINISTRATOR/
DIRECTOR:		MOLOCK, BRUCE E. JRFACILITY TYPE:
735
ADDRESS:44540 TAHOE WAYTELEPHONE:
(949) 594-9104
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 0DATE:
08/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:57 AM
MET WITH:Bruce Molock E. JRTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Evelin Rios conducted an announced Prelicensing  visit to complete Component III orientation. This is a new application for and Adult Residential Facility (ARF). LPA met with the applicant Bruce Molock E. JR. Fire clearance inspection was approved on 03/15/24 with the approved capacity for four (4) ambulatory clients. This is a (4) bedroom two (2) bathroom, single story home.

A tour of the physical plant inside and out was conducted with Bruce Molock E. JR at approximately 9:00 a.m.

Common Areas: These included dining area and living area. The common areas were checked for cleanliness and furniture was checked for functionality. All areas were clean, sanitary and furniture was in good repair. In the living area LPA observed a telephone, board games and sufficient space for activities. Dining table and couches sit the capacity of the facility. The facility was kept at a comfortable temperature.

Bedrooms: LPA inspected three (3) client bedrooms. One (1) bedroom is shared and has it's own private bathroom. LPA observed bedrooms to be properly furnished and had adequate lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress covers, and blankets.

Bathrooms: LPA observed all bathrooms to be clean, properly supplied with toilet paper, hand soup, and paper towels. LPA observed bathrooms had functional fixtures. Hot water temperature read 120 degrees Fahrenheit within regulation.

Smoke detectors and Carbon Monoxide detectors are interconnected and through out the facility. Applicant tested detectors at 9:30 a.m. and they were observed to be functioning properly. One (1) Fire extinguisher was observed by the kitchen, fully charged with purchase date 03/11/24.  (continued to LIC 809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PETRA RESIDENTIAL INC.
FACILITY NUMBER: 197610586
VISIT DATE: 08/28/2024
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(continued from LIC809)
Laundry/Garage: LPA observed the laundry room to be accessible to clients and staff. Detergents and cleaning supplies are maintained locked in the cabinet in the laundry room. The garage is accessible through a hallway.

Kitchen:  The kitchen appliances and fixtures appeared functional. LPA observed enough plates, bowls, cups and cutlery for the capacity of the facility. There was a sufficient amount of non-perishable foods properly stored in the kitchen pantry. The facility telephone is located on the kitchen counter and was not functioning properly during time of visit. Knives and sharps are locked in a kitchen cabinet inaccessible to clients. Medication will be locked in a kitchen cabinet. LPA observed a lock on the cabinet under the sink that stores cleaning product. There is a complete first aid kit with an up to date manual in a kitchen cabinet.

Office: LPA observed a cabinet in the office that can lock. Staff and clients files will be stored in the locked cabinet.

Surrounding Grounds (Outdoors): There is a covered patio for shade with proper outdoor furniture for client use. There are no bodies of water on the premises. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards.

The Component III presentation was conducted on site with Bruce Molock E. JR. at approximately 11:00 a.m. Pre-Licensing is incomplete with deficiencies to be resolved by09/06/2024. A follow up Pre-licensure LIC809 will be generated upon resolution of deficiencies."

Exit interview conducted and report signed and issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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