157204045-4-14-2023-24-AS-SMOA-CR7M3F-20230424091500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157204045
Report Date: 04/14/2023
Date Signed: 04/14/2023 09:57:17 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
03/15/2023 and conducted by Evaluator Mai Yang

COMPLAINT CONTROL NUMBER: 24-AS-20230315102447

FACILITY NAME:	IZENE'S HAVEN ASSISTED LIVING		FACILITY NUMBER:	157204045
ADMINISTRATOR:	BRUTON, MARGUERITE		FACILITY TYPE:	740
ADDRESS:	10000 COBBLESTONE AVE		TELEPHONE:	(661) 664-0125
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 3	DATE:	04/14/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Licensee Marguerite Bruton		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not provide authorized representative access to confidential documents
Staff did not issue a refund

INVESTIGATION FINDINGS:

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On 04/14/23, Licensing Program Analyst (LPA) M. Yang arrive unannounced visit to deliver the findings on the above allegation. LPA was greeted by Licensee Marguerite Bruton and was granted entry.

During the course of the investigation, LPA obtain record and conducted interviews. A copy of Admission Agreement was requested by letter by responsible party. Licensee stated no copy was provided to resident’s responsible party. Licensee stated a check was mailed late December 2022 to early January 2023. The responsibility party have not received the check that was mailed for the refund for the prorated amount after resident death. Based on records reviewed and interview conducted, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 are being cited on the attached LIC 9099D. An exit interview was conducted, and a Plan of Correction was reviewed and developed with Licensee. A copy of this report and appeal rights was provided to Licensee.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20230315102447

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: IZENE'S HAVEN ASSISTED LIVING	FACILITY NUMBER: 157204045
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/20/2023 Section Cited HSC 1569.652(c)	1 2 3 4 5 6 7	HSC 1569.652 (c) A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual... contractually responsible for the fees... within 15 days after the personal property is removed. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee agreed provided a copy of the resident’s Admission Agreement and issue a check to R1's responsible party and provide a copy of the check and a copy of the post office mailing receipt to the Fresno CCL office by the POC due date.
	8 9 10 11 12 13 14	Based on interviews conducted and record review, Resident 1 passed away on 10/02/22 and was not issued a refund for the remaining unused days to the resident’s responsible party. Licensee mailed the check late December 2022 early January 2023. The responsibility party have not received the check that was mailed. Responsible have not received a copy of the Admission Agreement as requested.This poses a potential health and safety risk to persons in care.	8 9 10 11 12 13 14	POC will clear when resident’s responsible party confirm record and money order has been received.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC9099 (FAS) - (06/04)

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