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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850761
Report Date: 07/08/2026
Date Signed: 07/08/2026 06:12:40 PM

Document Has Been Signed on 07/08/2026 06:12 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BROOKHAVEN AL AT LOS NOGALESFACILITY NUMBER:
565850761
ADMINISTRATOR/
DIRECTOR:		ATAKEEVA, GULIRAFACILITY TYPE:
740
ADDRESS:2761 LOS NOGALES AVETELEPHONE:
(805) 455-3532
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
07/08/2026
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Amanbek AtakeevTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Valeria Conway conducted an announced Pre-Licensing inspection visit and met with Licensee representative Amanbek Atakeev. An application to operate a Residential Care Facility for the Elderly (RCFE) was received on March 27, 2026. Fire clearance for five (5) non-ambulatory and one (1) bedridden residents was approved on April 22, 2026. The single bedridden occupant is approved for bedrooms #3, #4, #5 or #6. This pending facility has a dementia care program and a pending hospice care waiver for 6 (six) residents.

The LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The proposed physical plant is a single-family dwelling located in a residential neighborhood of Camarillo, CA. This facility will be housing residents with dementia. There are no clients residing in the facility at the moment.

At 10:00 A.M. a tour of the physical plant was conducted and the following observed:

COMMON AREAS: The home is a one (1) story home with a loft. The loft is above room #3 and it will be used as an office area designated for staff only and it will remain inaccessible to residents and secured with an indoor safety gate to prevent resident access. LPA observed a sunroom, a living and dining room area, a kitchen, six (6) resident bedrooms, two (2) share bathrooms and four (4) private bathrooms and one (1) staff room. Staff room is only accessible from the backyard.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2026
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 5
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BROOKHAVEN AL AT LOS NOGALES
FACILITY NUMBER: 565850761
VISIT DATE: 07/08/2026
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Continued from LIC 809

The living room, dining room and the sunroom are clean and properly furnished. The facility paint, floors, furnishings, fixtures and appliances are in good repair. Activities supplies were observed which included games, puzzles, and reading material for resident use. A working landline telephone is present for resident use. There are night lights in the hallways. At 11:08 A.M., the smoke alarms and carbon monoxide detectors were tested and operable. The fire extinguisher is charged and last serviced on April 6, 2026. All exits have functioning alarms. Indoor passages are free of obstruction. The LPA observed cameras in all common spaces and exterior. All required postings were posted in the common area of the facility. The facility has five (5) fire doors located in the dining room and resident rooms #3, #4, #5, and #6. During today’s visit, magnetic hold-open devices had not been installed on any of the fire doors. The licensee representative stated that the fire doors will remain closed at all times. LPA explained that door stoppers or other devices used to keep fire doors open are prohibited.

BEDROOMS: All residents’ bedrooms were observed. One bedroom was fully furnished with a bed, night stands, lamps, chairs and a chest of drawers. The other rooms are currently partially furnished. Room #2 has a cover and off-limit fireplace. LPA observed that some resident bedroom closets had curtains installed in place of closet doors, while other bedroom closets had neither doors nor curtains, leaving the closet the closet openings exposed. Designee stated that new curtains will be installed to cover the closet openings.

BATHROOMS: The residents’ bathrooms were observed to be clean and sanitary in operating condition with grab bars and slip-resistant mats. Solid waste containers are in good repair and have tight-fitting covers. Facility provides each resident privacy and personal accommodations. Between 10:13 A.M and 11 A.M., the hot water temperature was measured in all bathrooms and measured within regulation range of 105 and 120 degrees Fahrenheit.

KITCHEN: The kitchen and food service areas were observed. There is a walk-in closet that contains non-perishable food supplies. Perishable food will be supplied once license is approved. There is a sufficient supply of plates, cups, bowls and eating utensils for residents’ use. The kitchen also contained a locked drawer where sharps will be kept next to the stove. Some cleaning supplies will be locked and stored under the kitchen sink. At 10:20 A.M. the hot water temperature measured 114.8 degrees Fahrenheit.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BROOKHAVEN AL AT LOS NOGALES
FACILITY NUMBER: 565850761
VISIT DATE: 07/08/2026
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Continued from LIC 809-C

MEDICATION: Medication, resident files and a complete first aid kit will be stored in a locked pantry to the left of the kitchen sink. Facility will properly document medication on the Centrally Store Medication and Destruction log. During today’s visit LPA informed the Designee that removing medication from their original packaging in advance of administration (pre-popping) is not permitted.

LAUNDRY ROOM: LPA observed that the laundry room contains a washer and dryer. All chemicals and cleaning supplies will be stored in locked cabinets within the laundry room. Additionally, all extra linens and towels will be kept in this room. The laundry room is adjacent to the locked garage.

GARAGE: LPA observed a locked garage containing emergency disaster supplies, personal protective equipment (PPE), emergency food and water, and an additional refrigerator. The garage will also The garage will also be used to store extra tools and resident mobility equipment. Garage will remain locked and inaccessible to residents.

BACKYARD: Garden and yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. LPA observed that the backyard contains an outdoor seating area for residents. At the time of the visit, this seating area was not covered and did not provide adequate shade for anyone using the space. There are two (2) side gates. Only one (1) pathway is used as an emergency exit which was self-closing and latching mechanism and free of obstructions. LPA observed a shed containing yard tools and extra storage space. There were no bodies of water on the premises.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: LPA reviewed the facility's infection control practices and the facility's emergency disaster plan.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: BROOKHAVEN AL AT LOS NOGALES
FACILITY NUMBER: 565850761
VISIT DATE: 07/08/2026
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Continued from LIC 809-C

COMPONENT III ORIENTATION: A Component III Orientation was conducted with the Administrator during today's visit.

The following needs to be completed/Photos sent to LPA prior to licensure:

 Closets should have an appropriate door or other suitable covering.

 Purchase a tarp top carport cover to provide shade to residents in care.

 Install magnetic mechanisms and have them hardwired to the facility’s fire alarm system so the fire doors will automatically release and close upon activation. (optional)

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the Licensing Report was issued.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2026
LIC809 (FAS) - (06/04)
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