157204045-5-20-2025-24-AS-MYAG-DGUSMK-20250520140004

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 05/20/2025
Date Signed: 05/20/2025 02:00:23 PM

Document Has Been Signed on 05/20/2025 02:00 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/ DIRECTOR:	BRUTON, MARGUERITE		FACILITY TYPE:	740
ADDRESS:	10000 COBBLESTONE AVE		TELEPHONE:	(661) 664-0125
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	05/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	House Manager (HM)/ Designated representative Heidi Snavely		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

NARRATIVE

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On 05/20/25, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an annual visit. LPA introduce self, stated the purpose of the visit and requested to meet with Administrator. LPA met House Manager (HM)/ designated representative Heidi Snavely. LPA toured facility with designee. Licensee Marguerite Bruton was called and unable to attend meeting. All five residents were present in the living room during inspection.

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. All residents were reviewed. Medications were observed locked in kitchen shelves. LPA reviewed MARS and checked medications. An adequate supply of perishable and non-perishable food was observed. Refrigerator temperature is maintained at 32 degrees F and freezer at -2 degrees F. Fire extinguisher was observed with purchase date of 03/29/25. Extra linens were observed.

Approximately 11:31AM, Chemicals were observed unlocked in garage. 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 115.3 ang 115.8 degree F in the master bedroom and 114.4 degree F in hall bathroom. 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. At approximately 11:38AM, gardening tools were against facility wall outside unlock. Smoke detector and carbon monoxide was tested operational and functional during inspection.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 05/20/2025 02:00 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: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 observation and records reviewed, R1’s medications Lisinopril 20 mg and Clonidine Hcl 0.1 were not administered as directed by physician, which poses/posed an immediate health and safety risk for the person in care
	POC Due Date: 05/21/2025
	Plan of Correction
1 2 3 4	Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation to Fresno CCL office by POC due date 05/21/25.

Type A

Section Cited

CCR

87309(a)

87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Licensee did not comply with the section cited above when LPA and S1 observed chemicals unlock in the garage accessible to residents in care this poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/21/2025
	Plan of Correction
1 2 3 4	Staff immediately locked chemicals. POC cleared during visit.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/20/2025 02:00 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: 05/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HSC

1569.185(e)

HSC 1569.185(e) Fees for license or applications; use of revenues; collected; denial or forfeiture. The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement was not met by:
	Deficient Practice Statement
1 2 3 4	Based on records reviewed and interview conducted, the Facility has overdue Annual and Late Fees, this is poses/posed potential health and safety risk to residents in care.
	POC Due Date: 05/26/2025
	Plan of Correction
1 2 3 4	Licensee shall provide documents of annual fees have been renewed to CCL by due date 05/26/25.

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.

See Moua	TELEPHONE: (559) -65-7912
Mai Yang	TELEPHONE: 559-772-7402
	DATE: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

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: 05/20/2025

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A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D. A civil penalty is being assessed see attached Lic 421IM.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 05/23/25. Forms requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610E, control of property, current Administrator Certificate, and current liability insurance. A copy of this report and appeal rights was provided to the designee, 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: 05/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2025

LIC809 (FAS) - (06/04)

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