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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610013
Report Date: 09/23/2024
Date Signed: 09/23/2024 12:49:15 PM

Document Has Been Signed on 09/23/2024 12:49 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 LEXINGTONFACILITY NUMBER:
567610013
ADMINISTRATOR/
DIRECTOR:
ATAKEEVA, GULIRAFACILITY TYPE:
740
ADDRESS:1462 LEXINGTON CTTELEPHONE:
(805) 586-4020
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
09/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:43 AM
MET WITH:Gulira AtakeevaTIME VISIT/
INSPECTION COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a continuation of the required annual visit at 09:43AM. LPA initially met with facility staff. Licensee/Administrator was contacted via telephone and arrived at 09:50AM. Entrance interview conducted.

This visit is a continuation of the annual visit that began on 06/12/2024 and the physical plant was inspected during the initial visit. During today's visit a brief facility walk through was conducted. 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.

RECORD REVIEW: Began at 10:05AM, 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. 5 (five) resident records reviewed were complete and contained all required documents. 5 (five) staff files reviewed were complete and contained all required documents.

EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's emergency disaster plan, which was observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 08/02/2024.

MEDICATION REVIEW: Medications are stored in a large locked pantry. Medication review began at 12:17PM. Medications for 2 (two) residents were observed. Medications reviewed were documented and labeled in accordance with regulation.

DOCUMENTS REVIEWED: LPA observed a copy of the facility's liability insurance.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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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