565802459-9-18-2025-29-AS-DPEA-DMYVSB-20251031164116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 565802459
Report Date: 09/18/2025
Date Signed: 09/18/2025 06:14:34 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:	09/18/2025
		UNANNOUNCED	TIME BEGAN:	12:00 AM
MET WITH:	Amanbek Atakeev		TIME COMPLETED:	01:25 AM

ALLEGATION(S):

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Staff did not respond to resident's requests for assistance in a timely manner
Licensee retained resident requiring a higher level of care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Valeria Conway conducted an unannounced subsequent complaint visit to deliver finding for 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 the initial visit LPA and back-administrator toured the physical plant. LPA interviewed staff, Resident #1, hospice aide and hospice nurse and reviewed and obtained pertinent documents relevant to the investigation. During today’s visit a brief physical plant tour was conducted to ensure there are no health and safety concerns, and the facility is in compliance with Title 22 regulation. 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: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

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

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: 09/18/2025

NARRATIVE

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Continued from LIC 9099-C

Regarding allegation “Staff did not respond to resident's requests for assistance in a timely manner” as it was reported that during nighttime hours, staff do not respond to R1’s calls for assistance. The RP believes that staff may be sleeping during their shift, resulting in delays in providing care. To investigate the allegation, LPA Conway conducted interviews with R1, R1’s Power Of Attorney (POA), facility staff and the RP, as well as a review of facility documentation. During interviews, facility staff denied sleeping during overnight shift and reported that R1 rarely uses the call system, particularly during the night, as R1 believes they are still able to get up without assistance. Staff indicated that response times typically average 15 minutes, depending on whether staff are already assisting other residents at the time. Staff further stated that R1 is monitored every two (2) hours, including at night, or more frequently if necessary. R1 was interviewed and stated that staff generally respond in a timely manner when assistance is requested, although at times the response may take longer if staff are occupied. Interviews with other credible witnesses confirmed that R1 often avoids calling for help even when assistance is needed, as R1 prefers to remain independent. It was also brought to LPA’s attention that R1 does not like to carry their emergency call pendant around their neck, which limits their ability to request assistance promptly. Multiple individuals described R1 as reluctant to ask for help and at times disregarding the need to use the call system when support is necessary. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Staff did not respond to resident's requests for assistance in a timely manner” is deemed unsubstantiated at this time.

Regarding allegation “Licensee retained a resident requiring a higher level of care” it was reported that the RP’s expressed concern that R1 should reside in a medical facility with licensed nurses available at all times, rather than in a Residential Care Facility for the Elderly (RCFE). To investigate the allegation, the LPA conducted staff and resident interviews, reviewed records, and obtained information from the hospice agency providing services to R1.

Continued on LIC 9099-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:	DATE: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 09/18/2025

NARRATIVE

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Continued from LIC 9099-C

Record reviews and interviews revealed that R1 is visited by a Hospice Nurse (HN) every Tuesday and Friday to provide comfort care related to their medical diagnosis. In addition, a Hospice Aide (HA) visits every Monday and Thursday from 7:00 A.M. to 1:00 P.M to provide showers twice per week. The aide also supports R1 with activities, such as walking and exercise, as part of their hospice care plan. During an interview, the HN stated that R1 does not require ongoing skilled nursing care, does not have an active infection, does not present with behaviors that disrupt other residents, and does not have bedsores. The HN further explained that in the event of a medical change or emergency, the hospice agency has on-call nurses available 24/7 to respond to the facility and provide care as needed. Interviews with facility staff, including the back-up administrator, confirmed that staff are able to meet R1’s current care needs. Staff reported that R1 is monitored every two (2) hours, or more if necessary. LPA Conway interviewed R1 directly. R1 did not report any issues or concerns with the care and services being provided. No unmet needs have been observed by LPA. Based on the above information gathered although the allegations may be valid, there is insufficient evidence to support the allegation or that a violation occurred; therefore, the allegations “Licensee retained resident requiring a higher level of care” is deemed unsubstantiated at this time.

No citations issued. 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: 09/18/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025

LIC9099 (FAS) - (06/04)

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