565802459-9-15-2025-29-AS-DPEA-DMYVSC-20251031164117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802459
Report Date: 09/15/2025
Date Signed: 09/15/2025 10:15:46 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2025 and conducted by Evaluator Valeria Conway

COMPLAINT CONTROL NUMBER: 29-AS-20250908100909

FACILITY NAME:	BROOKHAVEN AL		FACILITY NUMBER:	565802459
ADMINISTRATOR:	ATAKEEVA, GULIRA		FACILITY TYPE:	740
ADDRESS:	1209 BROOKHAVEN AVENUE		TELEPHONE:	(805) 455-3532
CITY:	CAMARILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 5	DATE:	09/15/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Amanbek Atakeev		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff did not ensure resident received adequate nutrition
Staff did not assist resident with bathing as needed

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced 10-day complaint visit to investigate the allegations listed above. Upon arrival LPA met with back-up administrator, Amanbek Atakeev, and explained the reason for the visit. The administrator, Gulira Atakeeva, was unavailable during today's visit, but authorized the back-up administrator to sign today's report. Entrance interview conducted.

During today’s visit from 10:15 A.M. – 2:30 P.M. LPA and back-administrator toured the physical plant to ensure there are no health and safety concerns, and the facility is in compliance with Title 22 regulation. LPA interviewed staff, Resident #1, hospice aide and hospice nurse and reviewed and obtained pertinent documents relevant to the investigation. Please note that LPA Conway made attempts to contact Reporting Party (RP) upon receipt of this complaint, but RP was not available to provide additional details. The following was determined:

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 29-AS-20250908100909

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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	FACILITY NUMBER: 565802459
	VISIT DATE: 09/15/2025

NARRATIVE

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Continued form LIC 9099

Regarding the allegation: “Staff did not ensure resident received adequate nutrition” it was alleged that Resident #1 (R1) is only receiving three feedings per day and is not getting enough nutrition. R1 has a documented medical diagnosis of swallowing difficulties involving the mouth and throat (Sever Dysphagia). Due to this condition, R1 was prescribed a liquid special diet “NPO” (nil per os, nothing by moth) and long-term use of artificial nutrition upon admission to the facility in August 2024. The current hospice plan of care indicates that R1 is to be fed three (3) times daily using 4 to 4 1/2 cartons of Jevity 1.5 Calories per mL. of a doctor-prescribed liquid diet containing complete balanced nutrition and fiber. The Hospice Nurse (HN) stated that R1 is capable of communicating any discomfort or intolerance during feeding sessions, and that R1 remains alert, oriented and active throughout the day, including exercising and taking short walks. LPA requested weight logs and was informed by the HN that R1 is weighed approximately once every two (2) weeks. Records provided show an average weight of 137.5 as of September 12, 2025, with an increase in muscle mass based on latest measurement. At admission, R1 weighed 128 lbs. In an interview, R1 expressed satisfaction with the amount of liquid nutrition received, though R1 stated they would prefer solid food if possible. R1 also demonstrated understanding of their medical condition and dietary requirements. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violations occurred; therefore, the allegations “Staff did not ensure resident received adequate nutrition” is deemed unsubstantiated at this time.

Regarding the allegation of “Staff did not assist resident with bathing as needed” it was reported that Resident #1 (R1) often becomes sweaty; however, staff provide showers twice a week. Back up administrator reported that R1 is receiving hospice services, which include bathing twice a week. R1 is being seen by Hospice Nurse (HN) who visits every Tuesday and Friday, and a Hospice Aide (HA) who visits every Monday and Thursday. The HA provides showers. During today’s visit, the HA was present at the facility assisting R1. In an interview, the HA confirmed that R1 receives two (2) full showers each week in accordance with their established care plan. The aide, who has been caring for R1 since March 2025, denied ever observing R1 soiled, unclean, or with body odor.

Continued on LIC 9099-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

LIC9099 (FAS) - (06/04)

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Control Number 29-AS-20250908100909

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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	FACILITY NUMBER: 565802459
	VISIT DATE: 09/15/2025

NARRATIVE

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Continued on LIC 9099-C

Additional staff interviews reflected that caregivers assist R1 with bathing support as needed, including when R1 is sweating or after an “accident”. LPA conducted a private interview with R1 in their room. R1 stated that they would like to receive full showers more frequently but acknowledged that they have not made this request to caregivers, the administrator, agency nurses, or the back-up administrator. During observation, LPA noted that R1 appeared clean-shaved, wearing a clean shirt and no body odor was detected. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violations occurred; therefore, the allegations “Staff did not assist resident with bathing as needed” is deemed unsubstantiated at this time.

Exit interview was conducted. A copy of the report was provided via e-mail.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 09/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2025

LIC9099 (FAS) - (06/04)

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