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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 01/10/2022
Date Signed: 01/11/2022 10:40:13 AM

Document Has Been Signed on 01/11/2022 10:40 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:IZENE'S HAVEN ASSISTED LIVINGFACILITY NUMBER:
157204045
ADMINISTRATOR:BRUTON, MARGUERITEFACILITY TYPE:
740
ADDRESS:10000 COBBLESTONE AVETELEPHONE:
(661) 664-0125
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 3DATE:
01/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 PM
MET WITH:Marguerite Burton, LicenseeTIME COMPLETED:
10:30 PM
NARRATIVE
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On 01/10/222, Licensing Program Analysts (LPAs) L.Salazar and S. Doucette arrived at the facility unannounced to amend findings a complaint allegation. LPAs were greeted by Licensee, Marguerite Bruton. LPAs stated the purpose of the visit and was allowed entry into the facility by Licensee. LPAs had temperature taken upon entry to facility but COVID precautionary questions were asked at the time of entry.

During the course of complaint investigation, LPA Salazar and LPA Doucette observed the following deficiencies: Administrator Certificate is expired. Audit Request documentation was requested from Licensee to be sent to CCLD. Documentation states Licensee did not comply with request.

Deficiencies are being cited based on LPA's observation of records review and interviews conducted, and in accordance with the CCR Title 22. See LIC 809D.

An exit interview was conducted with Licensee Marguerite Burton. A copy of this report and appeal rights were discussed and provided to licensee. A plan of correction was developed by licensee and reviewed with LPAs.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2022
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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Document Has Been Signed on 01/11/2022 10:40 AM - It Cannot Be Edited


Created By: Lisa Salazar On 01/10/2022 at 01:09 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
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: IZENE'S HAVEN ASSISTED LIVING
FACILITY NUMBER: 157204045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2022
Section Cited
CCR
87755(c)

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87755 Inspection Authority of the Licensing Agency (c) The licensing agency shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the requirements in Sections 87412(f), 87506(d), and 87508(b). This requirement was not met evidenced by: Licensee did not respond to request for audit from Licensing which poses a potential health, safety and personal rights risk to residents in care.
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Plan of Correction POC - LPA will provide licensee with copy of CCLD's request for audit documentation by 01/12/2022. Licensee agrees to submit documenation requested by Auditor by POC date.
Type B
01/24/2022
Section Cited
CCR
87407(a)

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87407 Administrator Recertification Requirements (a) Administrators shall complete at least forty (40) classroom hours of continuing education during each two (2)-year certification period, including. This requirement was not met as evidenced by: Licensee does not have a current Administrator certificate which poses a potential health, safety and personal rights risk to residents in care.
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Plan of Correction POC Licensee agrees to complete Administrator certification by POC due date.

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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.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Lisa Salazar
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2022


LIC809 (FAS) - (06/04)
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