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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157204045
Report Date: 01/10/2022
Date Signed: 01/11/2022 10:20:36 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/15/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20211015163924
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: 2DATE:
01/10/2022
UNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Marguerite Burton, LicenseeTIME COMPLETED:
09:15 PM
ALLEGATION(S):
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Facility does not provide a safe environment for resident.
INVESTIGATION FINDINGS:
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On 01/10/2022, Licensing Program Analysts (LPAs) L.Salazar and Shawna Doucette arrived at the facility unannounced to amend findings on the above allegation. LPA was greeted by Licensee, Marguerite Bruton. LPAs stated the purpose of the visit and was allowed entry into the facility by Licensee. LPAs had temperature taken upon entry to facility COVID precautionary questions were asked at the time of entry.

Based on interviews and observation of additional information, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An exit interview was conducted with Licensee Marguerite Burton. A copy of this report and appeal rights were discussed and provided to licensee. A plan of correction was developed by licensee and reviewed with LPAs.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20211015163924
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: IZENE'S HAVEN ASSISTED LIVING
FACILITY NUMBER: 157204045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2022
Section Cited
CCR
87468.1
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(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by interviews and observation of videos taken of Resident on the ground after sliding out of bed. Resident R1 was on the ground for up to 10 hours. Licensee does not have written consent to video Resident.
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Licensee will obtain personal rights written consent from Resident to record video of Resident's behaviors.
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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: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2