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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 09/28/2022
Date Signed: 09/28/2022 06:18:27 PM


Document Has Been Signed on 09/28/2022 06:18 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:HIGH DESERT HAVENFACILITY NUMBER:
157209068
ADMINISTRATOR:MATHEW, ABRAHAMFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVDTELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:82CENSUS: 74DATE:
09/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Abraham Mathew
Janice Johnson		TIME COMPLETED:
06:30 PM
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On 9/28/22, Licensing Program Analysts (LPAs) M. Medina and L. Salazar arrived unannounced to conduct an Annual Required Inspection visit. LPAs allowed entrance through designated entry point. Visitor sign-in book available upon entry. LPAs conducted facility tour in Assisted Living and Memory Care buildings with Janice Johnson, Assistant.

Facility toured. Most bedrooms are private rooms, rooms with double occupancy have a minimum of 6-feet between beds. All resident bedrooms observed to have pull cords. Residents present during today's inspection observed to be participating in activities, sitting in common areas, or resting in their rooms. Medications are locked and secured in medication room. PPE is locked and secured and available if necessary.

Facility is equipped with a pull station and sprinkler alarm system. Fire extinguishers present with a service date of 4/19/22.

LPAs received copies of LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan, LIC 9020 Resident roster, and Monkeypox Infection Control Plan during facility inspection.

No deficiencies observed during Infection Control Inspection.

Exit interview conducted. Report signed on site and a copy provided to Administrator for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022
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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