157204045-2-16-2022-24-AS-MHON-CF5LEA-20220606084105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157204045
Report Date: 01/10/2022
Date Signed: 02/16/2022 01:20:06 PM

Substantiated

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
01/10/2022 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20220110135143

FACILITY NAME:	IZENE'S HAVEN ASSISTED LIVING		FACILITY NUMBER:	157204045
ADMINISTRATOR:	BRUTON, MARGUERITE		FACILITY TYPE:	740
ADDRESS:	10000 COBBLESTONE AVE		TELEPHONE:	(661) 664-0125
CITY:	BAKERSFIELD	STATE: CA	ZIP CODE:	93311
CAPACITY:	6	CENSUS: 3	DATE:	01/10/2022
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Marguerite Bruton, Licensee		TIME COMPLETED:	09:15 PM

ALLEGATION(S):

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Licensee does not have a fire clearance for bedridden resident.
Licensee does not have required facility postings
Licensee does not have staff associated to facility.

INVESTIGATION FINDINGS:

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On 01/10/222, Licensing Program Analysts (LPAs) L.Salazar and Shawna Doucette arrived at the facility to conduct the required 10-day site inspection. LPA was greeted by Licensee, Marguerite Bruton. LPAs had temperature taken upon entry to facility but COVID precautionary questions were asked at the time of entry.

LPAs toured the facility, reviewed resident and staff files. The Physician's report (LIC602) for Resident R1 states "bedridden" status, facility is not fire cleared for bedridden. Required Personal Rights posting are not posted in the facility. Staff S1 was not associated to facility.

This department has investigated the above allegations. Based on the LPAs Observation the preponderance of evidence standard has been met; therefore, the above allegation(s) is/are found to be substantiated.

Deficiencies are being cited based on LPA's observation, interviews conducted, and record review in accordance with the CCR Title 22. See LIC 9099D. Civil Penalties were issued for a Fire clearance and Fingerprint clearance.

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 Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20220110135143

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 87202(a)(2)	1 2 3 4 5 6 7	(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement was not met as evidenced by Resident R1's LIC 602 and review of facility file in Regional Office. Civil Penalty Assessed	1 2 3 4 5 6 7	Licensee will complete and submit the LIC 200 to include Resident R1's bedridden status per LIC602. Licensee will submit a copy of the facility sketch (LIC999) to LPA by POC date.
Type A 01/11/2022 Section Cited CCR 87355(e)(2)	1 2 3 4 5 6 7	87355 Criminal Record Clearance(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or which poses an immediate health, safety and personal rights risk to residents in care. This requirement was not met as evidenced by Facility Roster in the Guardian system. Civil Penalty Assessed	1 2 3 4 5 6 7	Licensee will call the Regional Office to verify Fingerprint transfer for staff are completed and all staff are associated to the facility by POC due date.
Type B 01/21/2022 Section Cited CCR 87468(c)	1 2 3 4 5 6 7	87468 Personal Rights (c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public.This requirement was not met as evidenced by: Licensee did not have personal rights posted in the facility which poses a potential health, safety and personal rights risk to residents in care.	1 2 3 4 5 6 7	Plan of Correction POC Licensee agrees to post personal rights LIC 613C2 by POC due date.
CCR	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (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)

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