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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607567
Report Date: 09/09/2025
Date Signed: 09/09/2025 02:34:04 PM

Document Has Been Signed on 09/09/2025 02:34 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.RO, 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:
09/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:MARIAN UKWAMEDUATIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 09/09/2025 at 11:15 am Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility to conduct an unannounced one (1) year required annual visit. LPA was greeted and allowed entry by staff who called Administrator, Marian Ukwamedua. LPA explained the purpose of the visit and Administrator arrived during the visit.

A tour of the physical plant was conducted with staff member at 11:30 AM. The facility has four (4) bedrooms, one (1) bedroom is designated for staff use and three (3) bedrooms are used for clients. There are two (2) bathrooms in the facility. The facility is fire cleared for four (4) ambulatory residents. All clients are currently attending program and were not present during the visit.

Infection control: The facility has an Infection Control Plan approved on 06/28/2022. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility.



Kitchen: At 11:40 am LPA conducted a tour of the kitchen and observed that the kitchen area is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of two (2) day perishable and seven (7) day nonperishable foods. Knives and medications are locked in a cabinet located adjacent to the kitchen. There is a fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and was last purchased on 09/09/25.

Continued on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CARROUSEL RESIDENTIAL
FACILITY NUMBER: 197607567
VISIT DATE: 09/09/2025
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Living and Dining: At 11:50 am LPA observed the living room and dining room areas, which were equipped with living room furniture, a television, tables, and chairs. The dining room table is large enough to accommodate all four (4) clients. There is a fireplace with a barrier, making it inaccessible to clients in care. No fireplace tools or fixtures were present. The smoke alarms are hardwired interconnected and were tested along with the carbon monoxide detector. The facility maintains a room temperature of 79°F.

Bedrooms: At 12:00 pm LPA observed all client bedrooms to be clean and properly furnished. Linen storage was also checked and observed to have an ample supply of clean linen and towels. Cleaning supplies and chemicals were observed to be locked in the hallway storage closet.

Bathrooms: At 12:15 pm LPA observed the bathrooms to be clean and sanitary with necessary supplies. Hot water temperature was measured at 106.5°F within the required range.

Garage/Laundry: At 12:30 pm LPA observed the garage to be attached to the facility and is currently being used for storage. LPA observed a freezer in the garage with additional frozen foods. The laundry room is located in the hallway leading to the garage.



Outside Area: At 12:40 pm LPA observed that there was no shaded area for residents, nor was there any furniture for clients to sit outside. Administrator showed LPA furniture stored in the garage due to recent windstorms in the area. The furniture will be returned to the outside area. No bodies of water on the premises. LPA observed a locked shed at the backyard being used as a storage.

Staff and Client Files: LPA conducted a file review of staff and client records at 1:00 pm.

Medications: At 2:00 pm LPA and Administrator reviewed medication and medication records.

Interviews: One interview with staff conducted. No interviews with clients as they were not present.

Administrative: Administrator emailed LPA bond certificate, client roster, Administrator certificate and LIC.500. Annual fee is current.

No citations issued. Exit interview conducted. A copy of this report was given to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
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