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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157204045
Report Date: 05/06/2022
Date Signed: 05/06/2022 01:38:53 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 LIVINGFACILITY NUMBER:
157204045
ADMINISTRATOR:BRUTON, MARGUERITEFACILITY TYPE:
740
ADDRESS:10000 COBBLESTONE AVETELEPHONE:
(661) 664-0125
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY:6CENSUS: 3DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Marguerite Bruton, LiTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident records are incomplete
Staff records are incomplete
INVESTIGATION FINDINGS:
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On 05/06/2022 Licensing Program Analyst (LPA) L. Salazar and A. Walton arrived at the facility unannounced to deliver findings on the above allegations.

LPA requested staff files when the complaint was opened. L1 was unable to provide did complete staff and resident files for LPA to review.

Based on the: LPA’s observation the preponderance of evidence standard has been met; therefore, the above allegations are 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 Bruton. 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 LPA.
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: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
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-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: 05/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
87606(a)
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87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information.
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Licensee will review all resident files and ensure all LIC forms are completed in their entirety, including . "Not appplicable" (N/A) may be used on the form for areas that are not applicable.
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This requirement was not met as evidenced by LPA observation of resident records. Required LIC forms are in the file, however, they are not completed in their entirety.
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Type B
05/20/2022
Section Cited
CCR
87654
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(g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.THis requirement was not met as evidenced by LPAs' observation at the time the complaint was opened, staff records were not complete and available.
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Licensee will ensure all personnel records are complete and up to date at all times. 2 out of the 3 staff no longer work at the facility. LPA observed staff files to have the required LIC forms. Health screeening for Staff S1 has been addressed in the annual insepction with a POC date of 06/06/22.
**POC cleared**
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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: 05/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2