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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 02/16/2022
Date Signed: 02/22/2022 07:16:09 AM

Document Has Been Signed on 02/22/2022 07:16 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:
02/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Marguerite Bruton, Licensee/AdministratorTIME COMPLETED:
03:20 PM
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On 2/16/22, Licensing Program Analyst (LPA) L.Salazar and Licensing Program Manager (LPM) Melinda Hoffmann, arrived at facility unannounced to follow up on Plans of Correction in relation to Facility Evaluation Report dated 1/10/22, at which time, deficiencies were cited for Inspection Authority and Administrator Certification Requirements. LPA and LPM were greeted by Licensee, Marguerite Bruton. LPM stated the purpose of the visit and was allowed entry into the facility. LPA and LPM had temperature taken upon entry to facility as COVID precautionary measure.

Plans of correction were not received on 1/24/22 and a POC visit was not conducted within 10 days of that date therefore the deficiencies are being re-cited in accordance with CCL Title 22, and new correction dates were provided, in the attached 809-D. Plans of correction were discussed with Licensee.

During today's visit, it was observed that R1 has full bed rails however R1 is not on hospice and does not have a Physician's order for the full rail therefore deficiency cited in accordance with CCL Title 22. Plan of correction discussed with Licensee.

Also observed today, was that R2 has a catheter and colostomy bag and there was no restricted health care plan and/or home health care plan in place to address the care with regard to these therefore deficiency cited in accordance with CCL Title 22. Plan of correction discussed with Licensee.

An exit interview was conducted. During the visit, technical issues were experienced and LPA and LPM left the facility for a short time to resolve the matter before returning to obtain hard copy signatures on the report. Appeal rights were provided to Licensee.


SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2022
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 02/22/2022 07:16 AM - It Cannot Be Edited


Created By: Lisa Salazar On 02/16/2022 at 12:37 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: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2022
Section Cited
CCR
87755(c)

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Inspection Authority of the Licensing Agency (c) The Licensee shall have the authority to inspect, audit, and copy resident or facility records upon demand during normal business hours..**This requirement was not met as evidenced by Licensee not responding to a request for audit from Licensing. This poses a potential risk to residents in care.
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Licensee will submit the records requested, to Licensing, by the POC due date.
Type B
03/04/2022
Section Cited
CCR
87407(a)

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Administrator Recertification Requirements (a) Administrators shall complete at least forty (40 classroom hours of continuing education during each two (2)-year ceritication period...**This requirement was not met as evidenced by Licensee not having a current Administrator certificate. This poses a potential risk to residents in care.
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Licensee will submit proof of current certification by the date or will appoint a qualified administrator who holds a current certification and shall submit a request to change the administrator, along with qualifying documents to make that change.

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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: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022


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Document Has Been Signed on 02/22/2022 07:16 AM - It Cannot Be Edited


Created By: Lisa Salazar On 02/16/2022 at 02:34 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: 02/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2022
Section Cited
CCR
87608(a)(3)

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Postural Supports.
A written order from a physician indicating the need for postural support shall be maintained in the resident’s record. **There is no Physician's order on file for R1's full bedrails. Immediate risk to resident in care.
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By tomorrow's due date, Licensee will submit a Physician's order for the bed rails or submit proof that the rails were removed from R1's bed. Proof may be a picture.
Type A
02/01/0333
Section Cited
CCR
87611(b)

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General Requirements for Allowable Health Conditions
(b) The licensee shall complete and maintain a current, written record of care for each resident that includes, but is not limited to, the following: (1)Documentation from the physician of the following:
(A) Stability of the medical condition(s); (B) Medical condition(s) which require incidental medical services;
(C) Method of intervention;
(D) Resident's ability to perform the procedure; and (E) An appropriately skilled professional shall be identified who will perform the procedure if the resident needs assistance.
(2) The names, address and telephone number of vendors, if any, and all appropriately skilled professionals providing services.
(3) Emergency contacts.
**R2 was observed to have a colostomy bag and catheter and no plan of care for these were on file. Immediate risk to resident in care.
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By tomorrow's due date, Licensee will submit a Plan of Care for R1, that includes the required elements as listed herein.

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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: 02/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2022


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