567610013-6-7-2021-29-AS-KDUK-C3RUJP-20210607153753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610013
Report Date: 06/07/2021
Date Signed: 06/07/2021 03:38:35 PM

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 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: 4	DATE:	06/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Gulira Atakeeva		TIME COMPLETED:	03:45 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

Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 2:25PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator/Licensee Gulira Atakeeva and discussed the reason for the visit. Entrance interview conducted.

The LPA, along with Administrator Gulira Atakeeva, toured the physical plant areas inside and outside at 2:30PM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total resident bedrooms downstairs; 4 (four) are private resident rooms and 1 (one) shared resident room. Upstairs is designated for staff use only and there is no resident access.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common dining room and living area were observed to be in good condition. The LPA observed the required postings in the entry way. 2 (two) fire extinguishers were observed to be serviced on 2/16/2021. All smoke detectors/carbon monoxide detectors are hardwired.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

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 2

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 AT LEXINGTON	FACILITY NUMBER: 567610013
	VISIT DATE: 06/07/2021

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

and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices at 2:50 PM. Upon entry, the facility has a central entry point for symptom screening in the facility entryway. The facility is allowing visitors indoors in the residents' private rooms or outside on the patio. 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.

The following recommendations were made:
- Although all residents are vaccinated, encourage residents to wear masks indoors in common areas, as tolerated

No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 06/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2