<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607567
Report Date: 08/10/2024
Date Signed: 08/10/2024 12:17:40 PM

Document Has Been Signed on 08/10/2024 12:17 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CARROUSEL RESIDENTIALFACILITY NUMBER:
197607567
ADMINISTRATOR/
DIRECTOR:		MARIAN UKWAMEDUAFACILITY TYPE:
735
ADDRESS:45532 STANRIDGE AVENUETELEPHONE:
(661) 206-7064
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
08/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:06 AM
MET WITH:Santa Perez - StaffTIME VISIT/
INSPECTION COMPLETED:
12:15 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
A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Santa Perez who called Administrator Marian Ukwamedua and purpose of the visit stated. The administrator designated Ms. Perez to sign the report. LPA observed that the four (4) residents were at the facility during visit. This facility is a North Los Angeles Regional Center (NLARC) vendored facility Level III.

A tour of the physical plant was conducted at 9:20 AM and the following was noted:

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted inside. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard and the front yard. The facility has sufficient stock of PPE in the garage.

The facility is a single storey house and has four (4) bedrooms on two (2) private and one (1) shared bedroom. One (1) bedroom is designated for staff use. There are two (2) bathrooms at the facility. There is no body water in the facility. The facility is fire cleared for four (4) ambulatory residents.

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at 110.1°F and within the required range. (continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/10/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARROUSEL RESIDENTIAL
FACILITY NUMBER: 197607567
VISIT DATE: 08/10/2024
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
26
27
28
29
30
31
32
(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary and free of pests. Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. Laundry area is located in a room leading to the garage. Knives and sharps are observed to be locked in the medication cabinet. All toxins, cleaning agents and laundry soap are locked in the cabinet along the hallway.
Fire extinguisher - There is a fire extinguisher located in the kitchen. Fire extinguisher was observed to be full and last bought on 09/25/23. Smoke alarms were hardwired and inter- connected, tested and observed to be operational. There is a carbon monoxide installed in the facility. Temperature of facility wall thermostat was set at 75°F and observed to be within the required range. Garage is attached to the house and could only be accessed through the Laundry room. The garage is also being used as frozen foods, PPE and other supplies storage and observed to be locked during visit. There is a shed at the backyard being used as a storage and observed to be locked during visit.

Medication was observed to be inaccessible and stored in a secured medication cabinet in the kitchen. There is a complete First Aid kit inside the medication cabinet.


Staff records were reviewed and appeared to be complete and updated. Clients’ records are also reviewed and appeared to be complete and updated.

Disaster drill was last conducted on 07/30/24. Required posting observed in facility (complaint hot line poster, personal rights, etc.).

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2