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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607567
Report Date: 10/14/2022
Date Signed: 10/14/2022 12:28:34 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2021 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20210806160459
FACILITY NAME:CARROUSEL RESIDENTIALFACILITY NUMBER:
197607567
ADMINISTRATOR:MARIAN UKWAMEDUAFACILITY TYPE:
735
ADDRESS:45532 STANRIDGE AVENUETELEPHONE:
(661) 206-7064
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 4DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Ukanaka NwokaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff yelled at residents.
Staff locked residents out of facility.
INVESTIGATION FINDINGS:
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LPA conducted an unannounced visit and was greeted by caregiver. LPA observed caregiver was wearing a mask and LPA's temperature was recorded. LPA confirmed the purpose of the visit was to complete the complaint which states staff yelled at residents and staff locked residents out of the facility. Caregiver confrimed there are four residents living in the facility.

LPA and caregiver toured the facility at 10:30 am. LPA did not observe any health or safety issues. A caregiver arrived at 10:45 am with a resident after assisting the resident to an apointemnt. Caregiver confirmed a resident was attending an adult day program.

LPA interviewed two staff members from 10:45 am until 11:10 am. LPA also interviewed the Administrator via phone at 11:10 am until 11:25 am. LPA reviewed resident's records at 11:15 am until 11:30 am.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20210806160459
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: CARROUSEL RESIDENTIAL
FACILITY NUMBER: 197607567
VISIT DATE: 10/14/2022
NARRATIVE
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LPA received an email from the reporting party (RP) who stated the resident who reported the allegations later stated to the RP the allegations were false. Also, both caregivers and the Administrator stated during LPA's interviews that staff did not yell at the residents and staff did not lock residents out of the facility.

Based upon LPA's interviews and the reporting party's statement that the allegations were not true, the allegations are unsubstantiated.

Exit interview conducted, appeal rights discussed, and a copy of the report was given to the caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2