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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 03/11/2022
Date Signed: 03/18/2022 10:17:39 AM


Document Has Been Signed on 03/18/2022 10:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
157204045
ADMINISTRATOR:BRUTON, MARGUERITEFACILITY TYPE:
740
ADDRESS:10000 COBBLESTONE AVETELEPHONE:
(661) 664-0125
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 4DATE:
03/11/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee Marguerite Bruton TIME COMPLETED:
01:45 PM
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On 03/11/22, Licensing Program Analysts (LPAs') L. Salazar and A. Walton arrived at the facility unannounced to conduct a Plan of Correction inspection. LPAs' were greeted by Licensee, stated the purpose of their visit and were allowed entry into the facility.

LPAs met with Licensee, and asked for the Plan of correction for deficiency cited on 02/16/2022. Licensee provided documentation for LPA to review.

LPA called Administrator Certification line who stated the information had not been received as of yet. Licensee provided a copy of a Fed Ex receipt showing documentation was sent to Sacramento's Administrator Certification address. LPA will follow up before POC date.

LPA is extending the POC date to 03/31/22 to allow LPA time to review documentation. LPA will return by POC date of 03/31/22.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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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