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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 07/27/2022
Date Signed: 07/27/2022 11:36:20 AM


Document Has Been Signed on 07/27/2022 11:36 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: 4DATE:
07/27/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Administrator, Marguerite BrutonTIME COMPLETED:
11:57 AM
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On 07/27/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an case management inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Marguerite Bruton.

The purpose of today's visit is to obtain the complete resident file for R1.

LPA will return the records to the facility/Licensee within 3 business days.

No deficiencies issued during today's inspection.

Exit interview conducted. A copy of this report was discussed and provided to Administrator, Marguerite Bruton, whose signature on this form confirms receipt of this document.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2022
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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