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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610525
Report Date: 09/16/2025
Date Signed: 09/16/2025 03:43:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 09/16/2025 03:43 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: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:
09/16/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Kalyse JacksonTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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On 09/16/2025 Licensing Program Analyst (LPA) Lorena Casillas arrived at facility for an unannounced one (1) year Required visit for this facility.

LPA Casillas arrived at 1:30 pm, LPA knocked but there was no one at the facility. LPA called and spoke to Administrator Edward Jackson who informed LPA that there are currently no clients, but that Co-Licensee Kalyse Jackson would be able to meet LPA. Co-Licensee arrived shortly after, LPA explained the reason for the visit and entrance interview was conducted.

A tour of the physical plant was conducted with designee at 2:30 pm. The facility has five (5) bedrooms and two (2) bathrooms currently occupying no clients. The tool kit was not used on this visit as there are no clients.

A tour of the physical plant was initiated at approximately 2:45 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.

Continued LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
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 3
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: BLUE ODYSSEY ADULT HOME
FACILITY NUMBER: 197610525
VISIT DATE: 09/16/2025
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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 06/30/25. Medication will be stored in a locked cabinet in the kitchen. The first aid kit is located in a locked kitchen cabinet.

BEDROOMS: At 3:00 pm LPA observed that 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 client’s bedrooms have beds, nightstand, chairs, dresser, bedding and linen. All rooms have sufficient lighting.

BATHROOMS: At 3:10 LPA observed that the facility has two (2) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. 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/CLIENT RECORDS: Staff and client records will be stored in a locked cabinet, located in the office. There are currently no staff or client records to review.

SURROUNDING GROUNDS: At 3:30 pm LPA observed that the driveway, passageways and entrance to the home were 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 body of water.

ADMINISTRATIVE: Annual fee is current.

No deficiencies noted. Exit Interview was conducted, and a copy of this report was given to Co-Licensee.

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

DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2025
LIC809 (FAS) - (06/04)
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