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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610580
Report Date: 06/24/2025
Date Signed: 06/24/2025 01:55:34 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/24/2025 01:55 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: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:
06/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Earlynn NarajosTIME VISIT/
INSPECTION COMPLETED:
02:00 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
On 06/24/2025 at 09:40am, Licensing Program Analyst (LPA) Lorena Casillas conducted unannounced annual inspection at the facility, LPA met with the Licensee/Administrator Earlynn G Narajos and conducted an entrance interview.

The facility has four (4) bedrooms and two (2) bathrooms. Per Fire clearance bedrooms #1, #2, #3 designated for a capacity of four 4 clients, and bedroom #4 is designated for staff/office use. Facility has awake staff at night.

A tour of the facility was conducted with Licensee and the following was observed: The facility currently does not have any clients, the tool kit was not used.

Common Area: At 10:00 am 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. 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 will have an adequate supply of two (2) days of perishable food and seven (7) day nonperishable foods once there are clients present. LPA observed dining ware to accommodate a maximum capacity of four (4). 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 will be inaccessible to clients. Cleaning supplies and chemicals are kept in a locked cabinet area in the laundry room and will be inaccessible to clients. The facility has one (1) fire extinguisher, and is observed to be full and last serviced on 06/20/2025.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2025
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)
Page: 2 of 3
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: 06/24/2025
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
Medications: LPA observed that medications along with first-aid kit will be/are kept centrally stored and locked in a cabinet in the kitchen area inaccessible to clients.

Bedrooms: at 10:20 am LPA observed three (3) bedrooms to be properly furnished and have appropriate bedding sheets, pillowcase, mattress pad, and blankets. Bedrooms have sufficient closet space, 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 to be 119.1°F. LPA observed appropriate grab bar and non-skid mat in each bathroom. All trash cans were observed to have lids.

Laundry Area: The laundry room is located in the separate area next to the kitchen. The washer/dryer appear to be in good condition. Laundry supplies and other chemicals are kept locked in the laundry cabinet, and inaccessible to clients.

Smoke/Carbon Monoxide Detectors: Smoke detectors and carbon monoxide were located throughout the facility. At 11:30 am 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.

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.

Administrative: Fees are current. Licensee emailed copy of Administrator Certificate and Bond.

Interviews: No interviews conducted as there are no clients or staff.

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

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

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3