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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607567
Report Date: 08/05/2022
Date Signed: 08/05/2022 12:54:04 PM

Document Has Been Signed on 08/05/2022 12:54 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:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Marian Ukwamedua, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Shira Stamps met with administrator Marian Ukwamedua for an unannounced one (1) year Required visit for this facility.

LPA arrived at 11:30 am and was greeted by caregiver Uka Nwoka. Three (3) clients were observed in the living room watching TV. The rest of the clients were observed to be in their rooms. The Administrator arrived at 12:00pm. LPA informed the Administrator of the purpose of the visit. Entrance Interview conducted.

Infection control: LPA reviewed the facility mitigation plan (approved on 03/16/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was signed in and sanitizer was available.

A tour of the physical plant was conducted with Administrator at 12:30pm. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. One (1) bedroom is designated for staff use only. The facility is Fire Cleared for four (4) ambulatory.

Food Inspection
LPA conducted tour of the kitchen at approximately 12:30pm and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives, sharp objects, and medications locked and inaccessible to client in care.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature at 80°F. CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARROUSEL RESIDENTIAL
FACILITY NUMBER: 197607567
VISIT DATE: 08/05/2022
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The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:40pm. There are two (2) fire extinguishers located in the kitchen. Fire extinguisher were observed to be full and last serviced on 06/25/22.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client.

Bathrooms
At 12:45pm LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 12:40pm and measured within regulation at 105.3 degrees F.

Laundry
LPA observed chemicals/hazardous items in a locked in the hallway closet.

Physical environment
LPA toured the outside area of the facility at 12:20pm. LPA observed appropriate outdoor furniture, with a covered shaded area for clients stored in the garage due to windy weather. No bodies of water on the premises.

Garage
LPA observed the garage to be attached to the facility and currently being used for storage, extra freezer, and PPE supplies.

Administrative: LPA collected the LIC.500.

An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
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