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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 09/28/2022
Date Signed: 10/03/2022 07:39:11 AM


Document Has Been Signed on 10/03/2022 07:39 AM - 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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Abraham Mathew, Administrator
Janice Johnson, Assistant 		TIME COMPLETED:
06:30 PM
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On 09/28/22, Licensing Program Analysts' L. Salazar and M. Medina arrived to the facility unannounced to conduct a case management visit based on multiple self reported incidents received. LPAs' were greeted by Assistant and the Administrator, stated the purpose of the visit and were allowed entry into the facility. COVID precautionary measures were taken at the time of entry.

LPAs toured the Assisted Living building and the Memory Care unit of the facility. Facility census is 49 in the Assisted Living building and 25 in the Memory Care unit. LPAs obtained facility resident roster, staff schedules for the months of July, August and September and records for 4 (four) residents in care. LPA Salazar will review records and return if needed.

No Deficiencies cited on today's visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
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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