197607567-10-24-2023-31-AS-ERIS-CWWS9L-20231024134056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607567
Report Date: 10/24/2023
Date Signed: 10/24/2023 01:41:04 PM

Document Has Been Signed on 10/24/2023 01:41 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CARROUSEL RESIDENTIAL		FACILITY NUMBER:	197607567
ADMINISTRATOR:	MARIAN UKWAMEDUA		FACILITY TYPE:	735
ADDRESS:	45532 STANRIDGE AVENUE		TELEPHONE:	(661) 206-7064
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 4	DATE:	10/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Marian Ukwamedua		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analysts (LPA) Evelin Rios and Christopher Alemoh met with administrator Marian Ukwamedua for an unannounced one (1) year Required visit for this facility. LPAs arrived at 10:30 a.m. and knocked on the door. Nobody answered. LPA Rios contacted the administrator Marine Ukwamedua who reported all clients were at day program. Administrator stated they will meet LPAs at the facility shortly. LPAs met with the Administrator and two staff at approximately 10:55 a.m. Four (4) clients were at their day programs. LPA informed the Administrator of the purpose of the visit. Entrance Interview conducted. Infection control: Facility is still following their infection control plan. LPAs observed appropriate Covid-19 signs on the entry walls. Administrator states the facility has enough PPE for 30 days. A tour of the physical plant was conducted with Administrator at approximately 11:00 a.m. The facility has four (4) total bedrooms one (1) bedroom is shared. One (1) bedroom is designated for staff use only. Kitchen: LPAs conducted a tour of the kitchen and observed there to be a sufficient supply of two-day perishables and seven-day nonperishable food, appropriately stored. The kitchen was observed clean and clear of clutter. LPA observed all knives, sharp objects, and medications locked in a large cabinet by the kitchen. Common Areas: This consisted of the two living areas and the dining area. LPAs observed the living areas and dining room to be clean and sit the capacity of the facility. The facility had a comfortable temperature of 75°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at approximately 11:10 a.m. There is (1) fire extinguisher located in the kitchen. Fire extinguisher has a purchased date of 09/25/2023. (Continued on to LIC809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/23/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: CARROUSEL RESIDENTIAL	FACILITY NUMBER: 197607567
	VISIT DATE: 10/24/2023

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(Continued from LIC809)

Client Bedrooms: LPAs observed bedrooms to be clean and properly furnished with adequate lighting. LPA observed additional bedding and linens sufficient for all of the clients in a closet in the hallway by the bedrooms. LPAs also observed chemicals/hazardous items locked in the hallway closet inaccessible to client in care..

Bathrooms: LPA observed all bathrooms to have the appropriate hand washing signs posted and were properly supplied with hand washing soup, toilet paper and paper towels. Hot water temperature in one (1) of two (2) bathrooms was measured 115°F which is within the required range.

Laundry/Garage: LPA observed the laundry room with a washer and dryer. The laundry room leads to the garage. The garage is used for storage, with an extra freezer, and PPE supplies.

Surrounding Grounds: Entry/exits were free from obstructions. The outdoor area was clean and has a large shed being used for storage. There is no body of water in the facility.

Client Files: With the assistance of the administrator, LPAs conducted a file review of client records
for proper documentation. Client records appeared complete and updated. Files are kept locked.

Staff Files: With the assistance of the administrator, LPAs conducted a file review of staff records to insure forms and training are up to date and in compliance. Files are kept locked.

Medications: Medications and Centrally Stored Medication Records were locked in a cabinet. Medications were observed properly labeled and stored. LPAs reviewed medications and medication documentation at approximately 12:10 p.m. and it was observed to be complete. There are two (2) first aid kits located in the facility with an updated manual.

There were no health and safety issue observed during todays visit. Exit interview conducted. Copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC809 (FAS) - (06/04)

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