157204045-6-6-2023-24-AS-MYAG-CSJTGB-20230606144253

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 06/06/2023
Date Signed: 06/06/2023 02:43:02 PM

Document Has Been Signed on 06/06/2023 02:43 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

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: 6	DATE:	06/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Licensee Marguerite		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 06/06/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA was greeted by Licensee (L1) Marguerite and was granted entry into the facility. LPA introduced self and stated the purpose of the visit. LPA conducted tour with L1. All six residents were present during inspection. The tour started in the common areas, into kitchen to resident's rooms. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Fire extinguisher was observed with purchased date 04/10/22. At approximately 12:06AM, LPA and L1 observed one resident medication cup fill for AM and one resident medication cup for noon both fill with medications on kitchen counter unlock. LPA reviewed residents’ MARS. First aid kit was observed and contained all required items. An adequate supply of perishable and non-perishable food was observed. Refrigerator maintained at a 58 degrees F. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. LPA observed 2 shared residents’ bed to be at least 6 feet apart and 2 single occupant bedrooms. Bathrooms were properly equipped. Hot water temperature 115.4 to in bathroom 1 and ranged between 116.1 degrees F to 116.4 degrees F in bathroom in the shared bedroom. Cleaning supplies and chemicals are kept in locked in laundry room. Outside of facility toured. Outside seating was observed available for residents. Side gate was self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational. A sample of residents’ file reviewed to have update Emergency contacts, Admission agreement, Pre-Appraisal form, and physician report. A sample of staff's files were also reviewed to have current First Aid/CPR, Personnel Record, Health Screening, and associated with facility.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: IZENE'S HAVEN ASSISTED LIVING	FACILITY NUMBER: 157204045
	VISIT DATE: 06/06/2023

NARRATIVE

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A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

An exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 06/13/23. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current liability insurance, control of property, and current Administrator. A copy of this report and appeal rights was provided to Licensee, whose signature on this form confirms receipt of this report.

SUPERVISOR'S NAME: See Moua	TELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/06/2023 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(d)(2)

87405(d)(2) Administrator-Qualifications and Duties. The administrator shall have the knowledge of and ability to conform to applicable laws, rules and regulations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, Fire extinguisher was observed with purchased date 04/10/22, which poses an immediate health and safety risk to the residents.
	POC Due Date: 06/07/2023
	Plan of Correction
1 2 3 4	Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 06/07/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 06/06/2023 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/06/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(c)(3)

87465(c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA reviewed all residents’ MARS and observed MARS was not initialed after medications was administered to residents. MARS was observed not initialed after medication administered for date 05/30/23 for 2 residents, date 05/31/23 for 4 residents, and date 06/06/23 AM for 4 residents. This is a potential health and safety risk for the residents in care.
	POC Due Date: 06/19/2023
	Plan of Correction
1 2 3 4	Licensee will submit documentation of staff training with staff rooster of attendance for training. Training shall include completing resident’s MARs after each medication is administered to the residents. Documentation and rooster shall be submitted to CCL by the POC due date of 6/19/23.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 06/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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