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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802459
Report Date: 12/17/2025
Date Signed: 12/18/2025 08:23:55 AM

Document Has Been Signed on 12/18/2025 08:23 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BROOKHAVEN ALFACILITY NUMBER:
565802459
ADMINISTRATOR/
DIRECTOR:		ATAKEEVA, GULIRAFACILITY TYPE:
740
ADDRESS:1209 BROOKHAVEN AVENUETELEPHONE:
(805) 455-3532
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 4DATE:
12/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Gulira AtakeevaTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:05 A.M., LPA met with Licensee/Administrator Gulira Atakeeva and back up administrator, Amanbek Atakeev. Entrance interview conducted.

Beginning at 9:25 A.M., 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. The facility serves residents with dementia, and the auditory alarms on the exit doors functioned properly at the time of visit. 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 11:05 A.M. and were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 07/12/2025.

BEDROOMS: There are 3 (three) total bedrooms, all of which are designated for shared resident use. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Continued on LIC 809

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2025
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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Document Has Been Signed on 12/18/2025 08:23 AM - It Cannot Be Edited


Created By: Valeria Conway On 12/17/2025 at 12:55 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
FACILITY NUMBER: 565802459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025

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
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Based on record review, the licensee did not comply with the section cited above by not having an updated needs and service plan for resident #1 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/01/2026
Plan of Correction
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Administrator created a new needs and service plan for resident #1 during todays visit and will review it with R1's family member before POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2025


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
FACILITY NUMBER: 565802459
VISIT DATE: 12/17/2025
NARRATIVE
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Continued from LIC 809

RESTROOMS: The LPA observed 2 (two) restrooms in the facility; 1 (one) is for shared use and 1 (one) 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. Hot water temperature was measured in both 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. The facility maintained a temperature of 71 degrees. LPA observed cameras throughout the common areas only. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for residents’ use. Facility has a side gate observed to be self-closing and self-latching gate with clear passageways for emergency exit use. All exits and passageways were observed to be free of hazards. The facility does contain a pool, which was observed to be gated and locked in compliance with regulation at the time of the visit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. Knives and cleaning supplies were observed to be locked and properly stored at the time of the visit. At 9:50 A.M. hot water measured at 110.8 degrees Fahrenheit.

Garage/Laundry room: The facility has a laundry room. The laundry room leads to the garage where cleaning supplies and disinfectants are kept. The garage remains locked and inaccessible to the residents in care. LPA observed a low supply of emergency water, extra food and additional PPE supplies are stored. During today’s visit a staff purchased additional emergency water supplies to ensure compliance. Technical Violation (TV) issued.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
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
FACILITY NUMBER: 565802459
VISIT DATE: 12/17/2025
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Continued from LIC 809-C

RECORD REVIEW: 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. Four (4) resident records were reviewed. LPA observed that Resident #1 (R1’s) most recently Needs and Services Plan was dated 10/25/2024, and the facility did not have an updated form on file. Four (4) staff files reviewed were complete and contained all required documents.

MEDICATION REVIEW: Medications review began at approximately 12:30 P.M. Medications are centrally stored and locked in a file cabinet inside a pantry in the kitchen area. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications were observed to be maintained and administered in compliance with regulation at the time of the visit. However, LPA observed that Resident #2 (R2) was missing their prescribed Senna medication for daily constipation. The administrator stated that R2’s family member had been notified of the low supply of the medication, that the last dosage was administered on 12/16/2025, and that the facility was awaiting a refill from R2’s family member. During the visit, the administrator contacted R2’s family member, who agreed to deliver the medication the same day. Technical violation (TV) issued.

During today's visit, LPA gathered the following items: LIC 500 and a copy of the facility's liability insurance. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually, at the time of the visit. Emergency drills are conducted quarterly, with the last drill documented on 11/02/2025.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or CA Health and Safety Code. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of the 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: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC809 (FAS) - (06/04)
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