567610013-7-7-2026-29-AS-VCOY-DVRT26-20260707142010

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610013
Report Date: 05/14/2026
Date Signed: 07/07/2026 02:20:57 PM

Document Has Been Signed on 07/07/2026 02:20 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BROOKHAVEN AL AT LEXINGTON		FACILITY NUMBER:	567610013
ADMINISTRATOR/ DIRECTOR:	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:	05/14/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:30 AM
MET WITH:	Amanbek Atakeev and Gulira Atakeeva		TIME VISIT/ INSPECTION COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA initially met with facility caretaker, Baatur Marishov. Licensee/Administrator, Gulira Atakeeva was contacted via telephone. Back-up Administrator, Amanbek Atakeev arrived shortly after. At 2:00 PM Licensee/Administrator arrived. Entrance interview conducted.

The LPA, along with Back-up 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 12:30 P.M. and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 11/20/2024. During today’s visit a fire extinguisher with service date of 07/12/2025 was brought into the facility. Administrator oversees more than one facility. LPA explained that each facility is required to maintain a fire extinguisher that is serviced annually. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

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.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
	VISIT DATE: 05/14/2026

NARRATIVE

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Continued from LIC 809

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 slip-resistant surfaces. Water temperature was measured in all restrooms 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. LPA observed surveillance cameras installed in the common areas of the facility as well along the exterior perimeter of the property.

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. Hot water was measured and measured at 117.7 degrees Fahrenheit.

GARAGE: 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. Facility has two total gates; both were observed to be self-closing and self-latching gates with clear passageways for emergency exit use. There were no bodies of water on the premises.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. Emergency disaster drills are conducted quarterly, with the last documented drill on 04/16/2026.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
	VISIT DATE: 05/14/2026

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Continued from LIC 809-C

RECORD REVIEW: Between 12:45 P.M. and 2:15 P.M., 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. LPA reviewed six (6) resident’s files. Resident records revealed that Resident #1 (R1), admitted on 05/05/2026, has no capacity for self-care and is bedridden. However, during today’s visit, LPA observed R1 seated in a wheelchair at the dining table eating lunch with guidance from staff. Administrator stated that R1 was recently admitted and that a new assessment will be conducted by R1’s physician to address information that may have been omitted from the current assessment. Additionally, LPA observed three (3) preplacement appraisal information forms that did not contain corresponding signatures. Technical Advised (TA) issued. Five (5) staff files reviewed were complete and contained all required documents.

MEDICATION REVIEW: Medications are stored in a large, locked pantry. In there, LPA observed file cabinets, emergency food and water and first aid kits. Medication review began at 2:30 P.M. Medications for four (4) residents were observed. Medications reviewed were documented and labeled in accordance with regulation. LPA observed that medication was being pre-popped in advance of administration. Technical Violation (TV) issued. During today’s visit LPA informed the Licensee/Administrator and the Back-Up Administrator that removing medication from their original packaging in advance of administration (pre-popping) is not permitted.

DOCUMENTS REVIEWED: LPA observed a copy of the facility's liability insurance, resident roster, and personnel record.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/07/2026 02:21 PM - It Cannot Be Edited

Created By: Valeria Conway On 05/14/2026 at 04:51 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BROOKHAVEN AL AT LEXINGTON	FACILITY NUMBER: 567610013
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(i)

Reappraisals

(i) When there is significant change in condition, as defined in Section 87101, Definitions, or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above as R1 had a change of condition after admission date and a new reappraisal was not conduted which poses a potential health risk to persons in care.
	POC Due Date: 05/29/2026
	Plan of Correction
1 2 3 4	Administrator will assess R1 and complete a new Needs and Service Plan. Also, they will get a new LIC 602A from R1's physician and submit both documents to LPA before 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.

	Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:

	Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026

LIC809 (FAS) - (06/04)

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