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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607567
Report Date: 07/15/2021
Date Signed: 07/15/2021 03:48:44 PM

Document Has Been Signed on 07/15/2021 03:48 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:CARROUSEL RESIDENTIALFACILITY NUMBER:
197607567
ADMINISTRATOR:MARIAN UKWAMEDUAFACILITY TYPE:
735
ADDRESS:45532 STANRIDGE AVENUETELEPHONE:
(661) 206-7064
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
07/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Santa Perez and Ukanaka NwokaTIME COMPLETED:
01:40 PM
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LPA Spaeth conducted an unannounced visit. LPA was greeted by caregivers Santa Perez and Ukanaka Nwoka at the front door. LPA observed both staff members were wearing a mask and staff members confirmed there are four residents. LPA was asked the COVID symptom questions and LPA's temperature was taken in the living room area. LPA observed the sign in area which included sign in sheet, thermometer, hand sanitizer, N95 masks, surgical masks along with other PPE supplies available for use. Caregiver unlocked a closet in the living room and LPA observed a 12-month supply of PPE. LPA also observed COVID signs within the living room area. LPA was then escorted to the family room, dining room, and kitchen combination. LPA observed three residents sitting in the family room watching television and the residents were social distanced.

LPA then observed an adequate supply of fresh fruits and vegetables in the refrigerator, frozen meats in the frozen section, an adequate supply of canned vegetables and pasta within the pantry. Caregivers unlocked a cabinet in the family room which contained medications and knives. LPA observed there were wash your hands sign, hand soap, paper towels, and a trash can in the kitchen. LPA then was escorted through a hall and observed the linens, cleaning supplies, and laundry detergent were locked. LPA then observed a locked door which was the staff room. LPA observed the laundry room which lead to the garage. LPA observed the garage was neat and clean. LPA was then escorted to the backyard and caregiver showed LPA the gate was not locked. LPA observed the staff/resident bathroom which contained wash your hands soap, paper towels and trash can. There are three resident room. Two female share the master bedroom which contains a bathroom and observed all COVID requirements in the master bathroom. There are no deficiencies to report, exit interview conducted and the report emailed to Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2021
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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