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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610525
Report Date: 08/13/2024
Date Signed: 08/14/2024 08:50:16 AM

Document Has Been Signed on 08/14/2024 08:50 AM - 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:BLUE ODYSSEY ADULT HOMEFACILITY NUMBER:
197610525
ADMINISTRATOR/
DIRECTOR:		JACKSON, EDWARDFACILITY TYPE:
735
ADDRESS:44238 MAHOGANY STTELEPHONE:
(661) 726-4345
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
08/13/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Edward JacksonTIME VISIT/
INSPECTION COMPLETED:
01:25 PM
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On 08/13/2024 at 10:00 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an announced Pre-Licensing Inspection with Licensee Edward Jackson. An application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on 07/25/2024. This facility is a five (5) bedroom house with two (2) bathrooms. A fire clearance was approved on 07/19/2024, for four (4) ambulatory clients for a total capacity of four (4). Bedrooms 1-4 are designated for ambulatory clients, the 5th bedroom is to be used as an office. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 10:00 am until 12:00 pm with Licensee.

A tour of the physical plant was initiated at approximately 12:10 pm and the following was observed:

COMMON AREAS: These included 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 up to four (4) clients. There were no visible immediate hazards. The smoke alarms are hard wired, inter-connected, were tested and are functional. The carbon monoxide detector is functional.

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave, oven and sink. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of four (4). Knives will be locked in a kitchen cabinet and are within a locked box. There is a fire extinguisher located in the kitchen and last purchased on 05/24/24. Medication will be stored in a locked cabinet in the kitchen. The first aid kit is located in a locked kitchen cabinet.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLUE ODYSSEY ADULT HOME
FACILITY NUMBER: 197610525
VISIT DATE: 08/13/2024
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BEDROOMS: There are four (4) bedrooms designated for client use. Room #1 through #4 are for one (1) ambulatory client each. Bedroom #5 is designated to be used as an office. The applicant furnished the client’s bedrooms with beds, nightstand, chairs, dresser, bedding and linen. All rooms have sufficient lighting.

BATHROOMS: The facility has two (2) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid material is embedded in the shower floors. The hot water delivered in the bathrooms measured within regulation between 105-120 degrees F. Bathrooms were supplied with wash your hands signs, paper towels and trash can have lids.

LAUNDRY ROOM: Cleaning detergents and supplies are locked in the laundry room area.



GARAGE: The garage is used for storage and has emergency water.

STAFF/RESIDENT RECORDS: Staff and resident records will be stored in a locked cabinet, located in the office. The applicant was advised to ensure that resident and staff records will be accessible to the licensing agency upon request or during inspection. Facility will have awake staff.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and backyard furniture. The facility backyard has sufficient yard space to accommodate outdoor activities. There is no swimming pool or bodies of water.

Exit Interview was conducted, and a copy of this report was given to applicant.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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