567610013-6-9-2020-29-AS-KHEN-BQEPR9-20200609113223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610013
Report Date: 06/09/2020
Date Signed: 06/09/2020 11:33:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME:	BROOKHAVEN AL AT LEXINGTON		FACILITY NUMBER:	567610013
ADMINISTRATOR:	ATAKEEVA, GULIRA		FACILITY TYPE:	740
ADDRESS:	1462 LEXINGTON CT		TELEPHONE:	(805) 586-4020
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 0	DATE:	06/09/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	G		TIME COMPLETED:	11:25 AM

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Licensing Program Analyst (LPA) Kristin Heffernan conducted a pre-licensing inspection for this proposed facility on 06/09/2020 at 09:30am. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime" with applicant representatives Gulira Atakeeva and Askar Atakeev. In addition, the residential care facility for the elderly (RCFE) inspection tool was not used during today’s inspection.

During today’s virtual visit, LPA inspected the proposed facility for fire safety, personal accommodations, and food service. Upon entrance, LPA observed appropriate Community Care Licensing and Long Term Care Ombudsman complaint posters, Rights to Resident Council, Personal Rights, and COVID-19 signage posted. All combination, hard-wired smoke alarms and carbon monoxide detectors were tested and function properly at this time. LPA observed one fire extinguisher in the kitchen to be fully charged. There will be no firearms/ammunition stored on the property. The applicant has obtained fire clearance for a total capacity of six residents, all of which may be non-ambulatory with one bedridden resident residing in bedroom #5.

There are four single-occupancy bedrooms and one double-occupancy bedroom for resident use. All resident bedrooms are located on the first floor. However, there is also a second level that contains two staff bedrooms and an office that will be inaccessible to residents. Bedrooms were furnished with appropriate bedding, chairs, nightstands and lamps. There is a sufficient supply of towels and linen. Each exit features a functional auditory alarm.

The facility has four full bathrooms for resident use, one of which is designated for staff and guests. There is also a full bathroom on the second story for staff. Resident bathrooms contained appropriate non-skid mats and secured grab bars.

Continued on LIC 809C...

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kristin Heffernan	TELEPHONE: (747) 230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

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, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
	VISIT DATE: 06/09/2020

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Due to the nature of the visit, LPA asked the applicant to use their own thermometer to test the proposed facility’s hot water at the kitchen sink. LPA observed the thermometer to read 110 degrees Fahrenheit. The kitchen also contained a locked drawer where sharps will be kept. Off the kitchen area, is a locked, walk-in closet that contains non-perishable food supplies, emergency water and provisions, first aid kits, and filing cabinets that will house medications and future staff and resident files.

The living area and dining areas are clean and properly furnished. The living room features a fireplace that was screened for safety. LPA also observed activities and games for resident use. The facility paint, floors, furnishings, fixtures and appliances are in good repair. A working landline telephone is present for resident use. A locked hall closet off of bedroom #5 contains chemicals, extra linen and extra hygiene supplies.

Building and grounds are free from hazard. The backyard features a covered patio space with a couch, chairs and table for future residents. There are no bodies of water. The property is completely fenced and gated with self-latching gates on both sides of the home. An attached garage contains a washer and dryer but will remain locked and inaccessible to residents.

Applicant explained both Component II and Component III were completed on 05/27/2020.

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.

A copy of this licensing report was emailed to the applicant representative for signature and requested to be returned on this date.

SUPERVISOR'S NAME: Alex Estrada	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kristin Heffernan	TELEPHONE: (747) 230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020

LIC809 (FAS) - (06/04)

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