<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 06/18/2024
Date Signed: 06/18/2024 03:40:08 PM


Document Has Been Signed on 06/18/2024 03:40 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 LIVINGFACILITY NUMBER:
157204045
ADMINISTRATOR:BRUTON, MARGUERITEFACILITY TYPE:
740
ADDRESS:10000 COBBLESTONE AVETELEPHONE:
(661) 664-0125
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 5DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Licensee Marguerite BrutonTIME COMPLETED:
04:00 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 06/18/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit.
introduce self, stated the purpose of the visit and requested to meet with Administrator. LPA met House Manager (HM) Heidi Snavely. LPA toured facility with HM. Licensee Marguerite Bruton was called and arrived later during inspection. Four residents were present upon inspection. One resident arrived later during inspection from day program.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside or outside. Medications were observed locked in kitchen shelves. LPA reviewed MARS and audit medications. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 36 degrees F and freezer at 0 degrees F. Fire extinguisher was observed with purchase date of 06/06/23. Extra linens were observed. Chemicals and sharps observed stored and locked in laundry cabinet. All bedrooms were observed to have the required furnishings and with adequate lightening. The bathrooms were toured and observed operational during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested at 120 degree F in the shared bedroom and 114.8 degree F in bathroom 1. Outside of facility toured and observed to be free of debris. Side gate observed self-closing and self-latching. Adequate outdoor seatings available for residents. All residents’ and staff files were reviewed to have all the required documents.



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

Exit Interview conducted. LPA received a copy of Lic 9020. The following documents are requested and submitted to Fresno CCL by: 06/24/24. Forms requested: Lic 308, Lic 500, Lic 610E, Administrator Certificate, and current liability insurance. A copy of this report and appeal rights was provided to the Licensee, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/18/2024 03:40 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
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 has a purchase date of 06/06/23, which poses an immediate health and safety risk to the residents.
POC Due Date: 06/19/2024
Plan of Correction
1
2
3
4
Fire extinguisher shall be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by POC due date 06/18/24.
Type A
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records reviewed and observation, all residents' MARS were reviewed, and all medications were audit, medications were not administered as directed by physician to 4 out of 5 resident, which poses an immediate health and safety risk for the person in care.
POC Due Date: 06/19/2024
Plan of Correction
1
2
3
4
Licensee shall submit documentation of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 06/19/24.

All staff in-service training shall be completed on Medications. Licensee will submit proof of training materials and staff attendance rooster to the Fresno CCL office by 07/01/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2