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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157204045
Report Date: 05/13/2024
Date Signed: 05/13/2024 09:39:56 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
05/07/2024 and conducted by Evaluator Mai Yang
COMPLAINT CONTROL NUMBER: 24-AS-20240507124638
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: 5DATE:
05/13/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Licensee Marguerite BrutonTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Facility staff are not properly addressing pest infestation in facility
INVESTIGATION FINDINGS:
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On 05/13/24, Licensing Program Analysts (LPA) M. Yang arrived unannounced to deliver findings on the
above allegation. LPA introduced self, stated the purpose of the visit, and met with Licensee Marguerite Bruton.

During the course of the investigation, LPA conducted interview, tour the facility, and reviewed records. Licensee confirm there is bed bugs and no pest control service in place.

Based on observation, interview conducted, records review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC 9099D. An exit interview was conducted. A copy of this report and appeal rights was provided to the Licensee, whose signature on this form confirms receipt of this report.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
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-20240507124638
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: 05/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/22/2024
Section Cited
CCR
87303(a)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement has not been met:

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Licensee is to submit pest control service receipt confirmation of facility has pest control service completed. Licensee shall submit a receipt of confirmation of the facility being free from bed bugs and/or an ongoing pest control service for bed bug by POC due date 05/22/24.
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Based on interviews conducted and records reviewed, Licensee confirmed bed bug have been seen in the facility and no pest control service is in place for bed bug which poses a potential health, safety or personal rights risk to persons in care.
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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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC9099 (FAS) - (06/04)
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