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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610580
Report Date: 06/18/2024
Date Signed: 06/18/2024 11:27:03 AM

Document Has Been Signed on 06/18/2024 11:27 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:CAROLSIDE ADULT HOMEFACILITY NUMBER:
197610580
ADMINISTRATOR/
DIRECTOR:		NARAJOS, EARLYNN G.FACILITY TYPE:
735
ADDRESS:44026 CAROLSIDE AVENUETELEPHONE:
(818) 859-3796
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
06/18/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Earlynn G Narajos-Administrator TIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 6/18/2024 at 10:00am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted an announced Pre-Licensing Inspection at the facility, met with the Licensee/Administrator Earlynn G Narajos and conducted an entrance interview.

This is a North Los Angeles Regional Center vendored facility and the licensee is planning to serve the client with intellectual disabilities at level three (03).
Fire Clearance was approved on 03/20/2024 for a maximum capacity of four (4) ambulatory clients. The facility has four (4) bedrooms and two (2) bathrooms. Bedrooms #2, #3, #4 designated for a capacity of four 4 clients, and bedroom #1 is designated for staff/office use. Facility will have an awake night shift staff on premises.
The physical plant was toured inside and out with the assistance of the Licensee.

Common Area: At 10:15am LPA observed the living/family room and dining room furniture to be clean and in good repair. The fireplace located in the family room is adequately closed and inaccessible. The facility maintains a comfortable temperature at 71°F. The air conditioner is operational. No firearms observed or will be maintained on the premises. LPA observed puzzles, books, balls, and board games to provide activities to residents in care.

Kitchen Area: The kitchen is equipped with a refrigerator, microwave, oven, and sink. The facility has adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food. LPA observed dining ware to accommodate a maximum capacity of six (6). The stove and the refrigerator were clean and in good operation. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to clients. Cleaning supplies and chemicals are\will be kept in a locked cabinet area in the laundry room and inaccessible to clients in care. The facility has one (1) new fire extinguisher, appeared to be full and serviced and were last purchased on 03/13/2024.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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: CAROLSIDE ADULT HOME
FACILITY NUMBER: 197610580
VISIT DATE: 06/18/2024
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Medications: LPA observed medications along with first-aid kit will be kept centrally stored and locked in a cabinet in the kitchen area and the key cannot be accessible to clients in use.
LPA also observed clients and staff files will be locked inside the staff/office room in the locked cabinet.
Facility has land-line which was checked at 11:05am to be operational.

Bedrooms: From 10:35am to 10:50am LPA observed four (4) bedrooms to be properly furnished and have appropriate bedding sheets, pillowcase, mattress pad, and blankets. Bedrooms are in good condition, have sufficient closet space and may be used for private or as shared. There is at least one chair, nightstand, and sufficient lighting for each client. LPA observed appropriate window screens. Sufficient supplies of personal hygiene products stored in the storage area will be provided to the clients by the Licensee.

Bathrooms: LPA toured two (2) bathrooms and checked to make sure bathrooms were clean and in good repair. All bathrooms are properly supplied with toilet papers, soap, and paper towels. The hot water temperature measured at 10:55am to be 103°F. LPA observed appropriate grab bar and non-skid mat in each bathroom. Trash cans have lids to protect consumers from cross contamination.

Laundry Area: The laundry room is located in the separate area next to the kitchen. The washer/dryer appear to be new and in good condition. Laundry supplies and other chemicals are kept locked in the laundry cabinet, inaccessible under supervision when not in use.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 11:05am they were tested and observed to be operational. No obstructions and or tripping hazards throughout the facility.

Outside areas: LPA toured the outside area of the facility. LPA observed the backyard is fully fenced and has sufficient yard space. There is an appropriate outdoor furniture with a covered shaded area for clients. There are no bodies of water. The side gate leading from the backyard to the front yard was not locked.

Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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: CAROLSIDE ADULT HOME
FACILITY NUMBER: 197610580
VISIT DATE: 06/18/2024
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The garage: LPA observed attached garage to the home, which is kept locked inaccessible to clients. It is currently being used as storage for additional supplies for clients. A second refrigerator is also located in the garage.

In addition to the Pre-Licensing inspection, a Component III power point presentation was conducted with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when the license has been approved.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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