567610013-4-27-2023-29-AS-KDUK-CRB4AD-20230427185546

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610013
Report Date: 04/27/2023
Date Signed: 04/27/2023 06:56:48 PM

Document Has Been Signed on 04/27/2023 06:56 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, 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: 6	DATE:	04/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Gulira Atakeeva		TIME COMPLETED:	07:05 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 11:04 AM. LPA was greeted and asked to sign in by facility staff. LPA then met with Licensee/Administrator Gulira Atakeeva. Entrance interview conducted. At 11:20AM, the LPA, along with the Licensee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: BEDROOMS: The facility is a two-story residence, however the upstairs area is designated for staff use only and is made inaccessible using a gate. LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The downstairs area of the facility consists of 5 (five) total bedrooms, 4 (four) are designated as private resident rooms and 1 (one) is designated as a shared resident room. RESTROOMS: Downstairs area contains 4 (four) total restrooms, 2 (two) of which are private restrooms and 2 (two) are designated as shared restrooms. All restrooms observed were clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 11:27AM, hot water measured at 124.7 degrees Fahrenheit in Room 1's private resident restroom and at 11:34AM, hot water measured at 125.2 degrees Fahrenheit in one of the shared resident restrooms. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished at the time of the visit. The LPA observed the fire extinguishers to be fully charged and last serviced on 02/15/2023. A fireplace was observed to be adequately screened and inaccessible to residents in care. At 04:40PM, fire alarms and carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level. 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: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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 AT LEXINGTON	FACILITY NUMBER: 567610013
	VISIT DATE: 04/27/2023

NARRATIVE

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KITCHEN: At 11:40AM, LPA observed the kitchen/dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives are stored in a locked drawer in the kitchen. Chemicals and cleaning supplies are stored locked under the sink. Access to the locked garage is through the kitchen. Garage was observed to be locked and contained additional food supply storage, as well as separate chemical storage and the laundry area.

OUTDOOR SPACE: At 11:47AM, the LPA observed the backyard, which has a covered outdoor area for resident use. There are no bodies of water noted. Gates on both sides of the facility are self-closing and self-latching.

RECORD REVIEW: Began at 11:55AM, staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. 1 (one) staff (Staff #1 - S1) of 5 (five) staff files reviewed did not contain a fingerprint background clearance. 2 (two) of 5 (five) staff files reviewed did not contain a health screening (S1 and Staff #2 - S2.) 3 (three) of 5 (five) staff files reviewed did not contain sufficient training documentation (S1, S2, and Staff #3 - S3.)

MEDICATION REVIEW: Began at 12:58PM. Medications for 5 (five) residents were observed. Prescription medications reviewed were documented and labeled in accordance with regulation. However, over the counter medications for Resident #1 (R1) and Resident #2 (R2) were not labeled per regulation. Additionally, R2 had prescription orders for calcium carbonate, but is using Calcium +D3 gummies instead and prescription for Rezyst Probiotic 250mg but is taking Culturelle probiotic gummies.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate.

INTERVIEWS: Beginning at 03:09PM, LPA interviewed 2 (two) staff and 2 (two) residents.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. A civil penalty was issued in the amount of $300. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 06:56 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.17(c)(1)(A)

Licensing

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, nterview, and record review, the licensee did not comply with the section cited above as one staff S1 has been working in the facility since 04/24/2023 and does not have a criminal record clearance which poses an immediate safety and personal rights risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	S1 left the facility during the visit. Licensee understands that S1 cannot work in the facility until a criminal record clearance is received for this individual. Proof of clearance will be sent to CCL once obtained.

Type A

Section Cited

CCR

87303(e)(2)

87303 (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... regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree 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 measured at 124.7 degrees Fahrenheit at 11:27AM in Room 1's private restroom and measured 125.2 degrees Fahrenheit at 11:34AM in the hallway restroom which poses an immediate safety risk to persons in care.
	POC Due Date: 04/27/2023
	Plan of Correction
1 2 3 4	Water temperature was turned down during today's visit and LPA re-tested to ensure the temperature was within range. Licensee will record water temperatures daily for 7 days, measuring water temperature at various times of the day and send the water temperature log to CCL by 05/08/2023.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 06:56 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 (two) out of 5 (five) staff files reviewed did not contain a health screening and 1 (one) of 5 (five) did not contain proof of TB test, which poses a potential health risk to persons in care.
	POC Due Date: 05/04/2023
	Plan of Correction
1 2 3 4	Licensee agreed to obtain a copy of S2's health screening. Licensee also agreed to obtain a health screening and TB test for S1 prior to S1 returning to work. Proof of health screenings will be sent to CCL by POC due date.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/27/2023 06:56 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(c)

Personnel Records

(c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 (three) of 5 (five) staff files reviewed did not contain proof of sufficient initial and ongoing training, which poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 05/11/2023
	Plan of Correction
1 2 3 4	Licensee agreed to complete all staff training and provide proof to CCL by POC due date.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC809 (FAS) - (06/04)

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