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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157204045
Report Date: 04/07/2022
Date Signed: 04/07/2022 07:16:16 PM


Document Has Been Signed on 04/07/2022 07:16 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
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:
04/07/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:53 PM
MET WITH:Marguerite BrutonTIME COMPLETED:
07:24 PM
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On 04/7/22, Licensing Program Analysts Les Xiong arrived at the facility unannounced to conduct a Plan of Correction inspection. LPA met with Licensee and informed her the purpose of the visit.

On 2/16/22, deficiencies were issued for Title 22, Sections 87755(c) and 87407(a) and the due date for the Plans of Correction (POC) was set at 3/4/22. Subsequently, an extension of the due date was approved to 3/31/22 however you have not submitted all of the documents requested by the Department’s auditor and have not submitted proof of administrator recertification. A review of active and pending administrator certifications indicates that your administrator certificate is not active and there is no re-certification pending at this time.

Because you have not submitted required and/or sufficient documentation to clear the deficiencies, civil penalties are being assessed in the attached and appeal rights provided.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les XiongTELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:
DATE: 04/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/07/2022
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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