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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 03/02/2022
Date Signed: 06/01/2022 09:09:55 AM


Document Has Been Signed on 06/01/2022 09:09 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/01/2022 08:42 AM

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

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This is an amended report.

On 3/2/22, Licensing Program Analysts (LPA)'s Shawna Doucette and Lisa Salazar arrived at the facility to commence a Case Management visit in relation to an LIC 624A death report submitted to licensing. LPA’s completed a facility visit using Covid-19 precautions. LPA's identified themselves and discussed the purpose of the visit with Administrator Abraham Mathew.

Upon review of records, it was observed that the resident had a prohibited condition.

No deficiencies were cited as a deficiency in relation to a prohibited condition involving another resident was cited in a separate report today and a plan of correction was developed to address this issue.

An exit interview was conducted with Administrator and a copy of this report was provided via email.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/01/2022 09:11 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/01/2022 08:47 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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


FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed


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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: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2