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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 09/16/2024
Date Signed: 09/18/2024 02:19:38 PM


Document Has Been Signed on 09/18/2024 02:19 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
SIERRA CASCADE AC/SC, 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: 78DATE:
09/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:51 PM
MET WITH:Administrator Linda PoythressTIME COMPLETED:
06:30 PM
NARRATIVE
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On 9/16/2024 Licensing Program Analyst (LPA's) B. Miranda and S. Douchette arrived at the facility unannounced to conduct a case management. LPA's met with Administrator Linda Poythress to go over the report.

LPA's interviewed Assisted Living Manager (ALM). LPAs asked if any resident's had recently been sent to the hospital, Assisted Living (ALM) stated R1 went to the hospital on 9/9/2024 and was also sent to the hospital the week before. LPAs asked if the incidents were reported to the Dept., ALM stated the incidents were sent to the Dept. by fax. LPAs asked ALM to provided the fax number the reports were sent to, but was not able to provide the number. LPAs asked to see the incident reports. Incident reports were provided but there was no fax confirmation attached. LPAs also conducted interviews were other residents who stated residents had been sent to the hospital within the past few weeks, ALM did not provide reports any additional reports.
Deficiency cited under Title 22, Division 6, Chapter 8.

Exit interview was conducted and a copy of this report LIC809, LIC809D, and appeal rights were provided to Administrator Linda Poythress via email.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
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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Document Has Been Signed on 09/18/2024 02:19 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/23/2024
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidenced by:
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Administrator will have a binder in office their office to verify reports have been sent within 7 days. Statement will be provided to LPA.
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Based on observation/ interview/ record review the licensee did not comply with the regulation listed above. This poses a potential health, safety, or personal rights risk to residents in care. LPA conducted multiple interviews which interviewees stated residents were sent to the hospital. Reports were not provided to LPAs and manager could not provide fax number.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2