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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850410
Report Date: 11/19/2025
Date Signed: 11/20/2025 07:20:04 AM

Document Has Been Signed on 11/20/2025 07:20 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 AL AT MOBILFACILITY NUMBER:
565850410
ADMINISTRATOR/
DIRECTOR:		ATAKEEV, AMANBEKFACILITY TYPE:
740
ADDRESS:1065 MOBIL AVENUETELEPHONE:
(805) 437-6951
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
11/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Amanbek AtakeevTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct the required annual visit at 10:15 A.M. LPA initially met with facility staff. Administrator, Amanbek Atakeev, was contacted via telephone and arrived at 10:45 A.M. Back-up administrator, Gulira “Gigi” Atakeeva, arrived shortly after. The reason for the visit was explained. Entrance interview conducted.

Beginning at 11:20 A.M., the LPA, along with 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, the auditory alarms on the exit doors were tested and functioned properly at the time of visit. The following was observed:

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 69 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 11:40 A.M. and function properly at this time. Fire extinguishers were observed to be fully charged and last serviced on 11/21/2025. The two (2) common living and dining areas are clean and properly furnished. LPA observed cameras in the common areas and outside perimeter of the property. Hygiene products were observed to be in a locked hallway closet.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2025
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 11/20/2025 07:20 AM - It Cannot Be Edited


Created By: Valeria Conway On 11/19/2025 at 03:44 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 MOBIL
FACILITY NUMBER: 565850410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 TB test result for Staff #1 readily available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/03/2025
Plan of Correction
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Administrator agreed to contact the medical office and get a copy of the TB test conducted. Once received, administrator will submit copy of negative TB test result to the LPA before the POC due date.

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: 11/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2025


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 AT MOBIL
FACILITY NUMBER: 565850410
VISIT DATE: 11/19/2025
NARRATIVE
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Continued from LIC 809

BEDROOMS: The facility has seven (7) bedrooms in total; six (6) are designated for resident use and one (1) is designated for staff use. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: The 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. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. Between 11:22 A.M. and 11:38 A.M. hot water was measured in all resident restrooms and measured within the required range of 105 - 120 degrees Fahrenheit.

KITCHEN: The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present. Kitchen appliances appeared to be in operable condition. Knives were observed to be stored in a locked drawer and cleaning supplies were locked under the kitchen sink. At 11:45 A.M. hot water measured at 114.1 degrees Fahrenheit.

LAUNDRY ROOM/GARAGE: Adjacent to the kitchen is a locked garage. Inside the locked garage LPA observed a washer and dryer, three (3) extra fridges with extra food for residents and staff, extra cleaning and PPE supplies, and extra storage room. Additionally, there was a sufficient amount of emergency food and water at the time of the visit.

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for residents’ use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use. A locked shed containing gardening tools was observed.

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. At 12:25 P.M. LPA reviewed five (5) resident records. All records were complete. At 1:09 P.M. LPA reviewed five (5) staff files including Administrator’s and observed that Staff #1 (S1) has a complete Health Screening Report (LIC503) indication they are able to work without restrictions; however, the tuberculosis (TB) test result was not available for review. The administrator reported that an X-ray had been completed prior to S1’s hire to clear them for employment, but the corresponding X-ray documentation could not be located during the visit.

Continued on LIC 809-C

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

DATE: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
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 AT MOBIL
FACILITY NUMBER: 565850410
VISIT DATE: 11/19/2025
NARRATIVE
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Continued LIC 809-C

MEDICATION REVIEW: At 2:15 P.M. medications for five (5) residents were observed. Medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A), a copy of the facility's current liability insurance, and the current Emergency and Disaster plan. Emergency disaster drills are conducted quarterly, with the last drill documented on 08/01/2025. Technical Advisory (TA) Issued.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) 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: 11/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2025
LIC809 (FAS) - (06/04)
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