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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802459
Report Date: 11/16/2022
Date Signed: 11/17/2022 11:27:58 AM


Document Has Been Signed on 11/17/2022 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:BROOKHAVEN ALFACILITY NUMBER:
565802459
ADMINISTRATOR:ATAKEEVA, GULIRAFACILITY TYPE:
740
ADDRESS:1209 BROOKHAVEN AVENUETELEPHONE:
(805) 455-3532
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:6CENSUS: 4DATE:
11/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Gulira AtakeevaTIME COMPLETED:
03:35 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 02:38PM. This annual had a specific emphasis on infection control practices and procedures. LPA met with Licensee Gulira Atakeeva. Entrance interview conducted.

The LPA, along with Licensee, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher was observed to be fully charged and last serviced 02/11/2022. Hardwired smoke detectors/carbon monoxide detector was tested and was functional at the time of the visit.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, family room, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. The living room has a fireplace, which was adequately screened.

The backyard has a covered outdoor area equipped with furniture for resident use. The facility has an in-ground pool, which is secured by a fence and padlocked gate. The garage was observed locked and contained the laundry area, as well as emergency food supply, and storage.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Only the downstairs area is accessible for resident use, therefore LPA observed only the downstairs area. Downstairs, there are 3 (three) total bedrooms; all of Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BROOKHAVEN AL
FACILITY NUMBER: 565802459
VISIT DATE: 11/16/2022
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which are designated for shared resident use. Staff bedrooms are located upstairs.

RESTROOMS: The LPA observed 2 (two) restrooms downstairs in the facility; one is a shared restroom and one is a private restroom. Resident restrooms were observed clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was checked in shared resident restroom and measured at 115.1 degrees Fahrenheit, which is within the required range.

INFECTION CONTROL: Following today’s in person visit, the LPA called and spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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