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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157204045
Report Date: 05/06/2022
Date Signed: 06/03/2022 02:31:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/10/2022 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20220110135143
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: 2DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Marguerite Bruton TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff Records are incomplete
Resident Records are incomplete
INVESTIGATION FINDINGS:
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On 05/06222, Licensing Program Analysts (LPAs) L.Salazar and Alexandria Walton arrived at the facility to deliver findings on the above allegations. LPAs were greeted by Licensee, Marguerite Bruton, stated the purpose of visit and we allowed entry. COVID precautionary measures were taken at the time of entry.

During the investigation, LPA reviewed resident and staff files, which were found to be incomplete. without the required LIC forms. Based on the LPAs observations the preponderance of evidence standard has been met; therefore, the above allegations are found to be substantiated.

Deficiencies are being cited based on CCR Title 22. See LIC 9099D. A plan of correction was developed. Plan of correction was provided by licensee and reviewed with LPA.

An exit interview was conducted with Licensee Marguerite Burton. A copy of this report and appeal rights were discussed and provided to licensee.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20220110135143
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 LIVING
FACILITY NUMBER: 157204045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
87506(a)
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87506 Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
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Licensee completed resident files per the LIC 311F provided to L1 by LPA. L1 submitted proof to correction at the time of visit.
**POC cleared**
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This requirement was not met as evidenced by LPA's request for resident records and Licensee was unable to provide the required documents in the LIC 311F.
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Type B
05/06/2022
Section Cited
CCR
87412(a)
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87412 Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:(4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license.
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Licensee completed staff files per the LIC 311F provided to L1 by LPA. L1 submitted proof to correction at the time of visit.
**POC cleared**
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This requirement was not met as evidenced by LPA's request for resident records and Licensee was unable to provide the required documents in the LIC 311F.
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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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2