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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850410
Report Date: 11/08/2023
Date Signed: 11/08/2023 01:53:14 PM

Document Has Been Signed on 11/08/2023 01:53 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:BROOKHAVEN AL AT MOBILFACILITY NUMBER:
565850410
ADMINISTRATOR:ATAKEEV, AMANBEKFACILITY TYPE:
740
ADDRESS:1065 MOBIL AVENUETELEPHONE:
(805) 437-6951
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 0DATE:
11/08/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:12 AM
MET WITH:Amanbek Atakeev & Gulira AtakeevaTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 09:12AM. LPA met with applicant representatives Gulira Atakeeva, Askar Atakeev, and Administrator Amanbek Atakeev. The applicant has obtained fire clearance for five (5) non-ambulatory and one (1) bedridden with a total capacity of six (6) residents. The proposed facility has a pending Dementia care plan and a pending hospice care waiver for four (4) residents. Applicant completed component II interview on 11/07/2023. During today's visit, Applicant representatives and Administrator completed component III with the LPA.

Beginning at 09:55AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 10:30AM and function properly at this time. Fire extinguishers were observed to be fully charged and recently purchased. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The two (2) common living and dining areas are clean and properly furnished. A properly screened fireplace was observed in the living room. A working telephone is present.

The proposed facility has seven (7) bedrooms total; six (6) are designated for resident use and one (1) is designated for staff use. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. The proposed facility has four (4) bathrooms, one (1) is located in the hallway and is designated for shared use and three (3) are for private resident use. Hot water was measured in a sampling of resident restrooms and measured within the required range.

The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of emergency water. Knives will be stored in a locked drawer and cleaning supplies will be stored locked under the sink. Adjacent to the kitchen is a locked cabinet for medication and file storage, as well as first aid kit. Locked garage contained the laundry area, extra food supply, emergency supplies and backup generator for emergency use.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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 MOBIL
FACILITY NUMBER: 565850410
VISIT DATE: 11/08/2023
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Building and grounds were observed. Patio area contains a shaded seating area for future resident use. A locked shed was observed. Outdoor exit gates were observed be self-closing and self-latching.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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