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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 05/06/2022
Date Signed: 05/06/2022 12:33:00 PM

Document Has Been Signed on 05/06/2022 12:33 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, 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:
05/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Administrator, Marguerite BrutonTIME COMPLETED:
12:39 PM
NARRATIVE
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On 05/06/2022, Licensing Program Analysts (LPAs) Walton and Salazar arrived unannounced to conduct an Annual Inspection - Infection Control. LPAs introduced themselves, stated the purpose of the visit and requested to meet with the Administrator. LPAs met with Administrator, Marguerite Bruton. Facility has one central entry and exit point. Facility has implemented a sign in policy for visitors.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and dining areas. Bathroom did have a trash cans with lid. Hand washing posters were observed by the bathroom sinks. Bedrooms are single occupant.

LPAs checked residents’ locked medications. Overflow medications were observed to be locked with cleaning supplies. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility does have an adequate supplies of required PPE. Staff records were reviewed, LPAs did not observe a health screen for facility staff. Per Administrator, S1 does not have a health screen. Facility staff was observed with mask on. Residents wear masks when away from the facility. Resident’s files did not have updated emergency contact information.

LPAs are requesting the following documents be submitted to the Fresno CCL office by 05/20/2022: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond, and the Mitigation Plan (LIC808)

CONTINUED TO 809C

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
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.

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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: IZENE'S HAVEN ASSISTED LIVING
FACILITY NUMBER: 157204045
VISIT DATE: 05/06/2022
NARRATIVE
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Based on observation and interviews, a deficiency is being issued in accordance with the California Code of Regulations, Title 22, Division 6 on the attached 809D.

Exit interview conducted and a Plan of Correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Marguerite Bruton, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/06/2022 12:33 PM - It Cannot Be Edited


Created By: Alexandria Walton On 05/06/2022 at 12:03 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: 05/06/2022

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 interview and record review, the licensee did not comply with the section cited above when 1 out of 1 personnel did not have a health screen within in 7 days after employment which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2022
Plan of Correction
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Licensee agreed to have S1 obtain a health screen and will provide proof that S1 obtained a health screen to the Fresno CCL office by 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.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
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


LIC809 (FAS) - (06/04)
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