567610013-6-12-2024-29-AS-KDUK-D66NFM-20240612102547

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610013
Report Date: 06/12/2024
Date Signed: 06/12/2024 10:25:56 AM

Document Has Been Signed on 06/12/2024 10:25 AM - 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:	06/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Gulira Atakeeva		TIME COMPLETED:	10:30 AM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:13AM. LPA initially met with facility staff. Licensee/Administrator was contacted via telephone and arrived at 09:40AM. Entrance interview conducted.

Beginning at 09:46AM the LPA, along with Licensee/Administrator 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. Please note: the facility is a 2-story house; the upstairs area is inaccessible to residents in care and is used for staff only, therefore was not observed. The following was observed in the downstairs area:

Hardwired combination smoke and carbon monoxide detectors were tested at 10:03AM and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 02/21/2024.

BEDROOMS: There are 5 (five) total bedrooms; 4 (four) are designated for private resident use and 1 (one) is a shared bedroom. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: The LPA observed 4 (four) restrooms in the facility; 1 (one) is for shared use, 1 (one) is designated for staff and visitors and 2 (two) is designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Water temperature was measured in the shared resident restroom and measured within the required range.

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. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care.

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: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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: 06/12/2024

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KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

Locked garage is located adjacent to the kitchen. Garage was observed and contained extra food, emergency food, cleaning supplies and storage, as well as laundry area.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards.

RECORD REVIEW: Will be reviewed during the annual continuation visit.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA will review the emergency disaster plan during the annual continuation visit.

MEDICATION REVIEW: Medications were observed to be in a locked large pantry. Medications were not reviewed during today's visit. First aid kit was observed to be complete.

INTERVIEWS: Throughout the visit, LPA interviewed 1 (one) resident. Additional interviews will be conducted during the annual continuation visit.

LPA will return at a later date to continue the annual inspection.

No citations issued. 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: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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