567610013-6-2-2022-29-AS-KDUK-CEZVAS-20220602161625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610013
Report Date: 06/02/2022
Date Signed: 06/02/2022 04:17:17 PM

Document Has Been Signed on 06/02/2022 04:17 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
CCLD Regional Office,
, CA

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: 6	DATE:	06/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Gulira Atakeeva		TIME COMPLETED:	03:35 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 2:00PM. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Licensee Gulira Atakeeva and discussed the reason for the visit.

The LPA, along with facility 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:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. A fireplace was observed to be covered and inaccessible to residents in care. The LPA observed the required postings in the common area. Fire extinguishers were observed to be fully charged and last serviced 02/11/2022.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. 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. There are 5 (five) total bedrooms; 4 (four) are private resident rooms and 1 (one) is a shared resident room. The upstairs area is designated for staff use only and was gated rendering it inaccessible to residents in care.

Report Continued on LIC 809-C

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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,
, CA

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
	VISIT DATE: 06/02/2022

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RESTROOMS: The LPA observed 4 (four) restrooms in the facility; 1 (one) is a shared restroom, 2 (two) are private restrooms and one is designated for staff and guests. Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature in the shared resident restroom measured at 134.0 degrees Fahrenheit at 2:28PM and 125.2 degrees Fahrenheit at 3:12PM after adjusting the water heater and a private resident restroom's water measured at 125.8 degrees Fahrenheit at 3:14PM.

INFECTION CONTROL: During today’s visit, the LPA 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 has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The facility’s policies and procedures as it pertains to infection control are adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/02/2022 04:17 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as water temperature in the shared resident restrooom measured at 134 degrees Fahrenheit at 2:28PM and 125.2 degrees Fahrenheit at 3:12PM after adjusting the water heater and a private resident restroom's water measured at 125.8 degrees Fahrenheit at 3:14PM which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/10/2022
	Plan of Correction
1 2 3 4	Licensee adjusted the water heater during today's visit. Licensee will measure water temperatures daily, record the water temperatures for one week and send the LPA a log indicating the week's water temperatures by 06/10/2022.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:	TELEPHONE:
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE:
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC809 (FAS) - (06/04)

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