Community Care Licensing

Document Has Been Signed on 10/10/2024 06:39 PM - It Cannot Be Edited

FACILITY NAME:	HIGH DESERT HAVEN		FACILITY NUMBER:	157209068
ADMINISTRATOR/ DIRECTOR:	MATHEW, ABRAHAM		FACILITY TYPE:	740
ADDRESS:	1240 COLLEGE HEIGHTS BLVD		TELEPHONE:	(760) 371-1989
CITY:	RIDGECREST	STATE: CA	ZIP CODE:	93555
CAPACITY: 82		CENSUS: 73	DATE:	10/10/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	07:39 AM
MET WITH:	Administrator Linda Poythress		TIME VISIT/ INSPECTION COMPLETED:	07:00 PM

SUPERVISORS NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Shawna Doucette LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Link to Parent Document Below:

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in several Resident Rooms on the Assisted Living side of the facility measured over 120 F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a photo of the water temperature for Room 103, Room 121, Room 137 and Room and Room 108 showing a temperature between 105 F and 120 F by POC due date 10/11/24.

Type A

Section Cited

CCR

87465(a)(4)

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not administer 6 pills of R1's medication, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a medication training and submit an agenda with date of training by POC due date 10/11/24. Civil Penalty was issued for repeat violation.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Shawna Doucette LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Link to Parent Document Below:

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type B

Section Cited

CCR

87303(a)

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) , the licensee did not comply with the section cited above in Licensee has a broken window near the dining room, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a photo of the window replacement by POC due date 10/18/24.

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have training for staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit staff training to meet this regulation by POC due date 11/29/24.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Shawna Doucette LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Link to Parent Document Below:

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type B

Section Cited

CCR

87465(a)(6)

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above Licensee has 4 bottles of Lisinipril containing 90 pills in each bottle logged for R4 with start dates of 6/10/24, 07/13/24, 09/1/24 and 1/11/25 (could not have started medication on 1/11/25 when the date has not occurred, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/25/2024
	Plan of Correction
1 2 3 4	Licensee agrees to conduct a staff training on logging medications and submit training and agenda who conducted training and hours of training by POC due date 10/25/24.

Type B

Section Cited

HSC

1569.69(g)

(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have documentation of a licensed professional reviewing medication management program that meets this regulation which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/01/2024
	Plan of Correction
1 2 3 4	Licensee agrees to schedule a consultation to meet this regulation and submit a date the consult is occurring and proof of consult by POC due date 11/01/2024.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Shawna Doucette LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Link to Parent Document Below:

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type B

Section Cited

CCR

87506(b)(15)

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not fill out admissions agreement for R3 and R9 showing each resident has their own room when its a shared room and shows each are paying for a individual room and not a shared room, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Licensee agrees to update R3 and R9's admissions agreement and submit a copy to Licensing by POC due date 10/18/24.

Type B

Section Cited

CCR

87507(d)

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not put updated rate increase letters in resident files which are effective 11/1/24, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Licensee agrees to put letters sent to residents in each resident file reflecting rate increase by POC due date 11/1/24.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Shawna Doucette LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Link to Parent Document Below:

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type B

Section Cited

CCR

87609(b)(4)(A)

(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s). (A) The written agreement shall reflect the services, frequency and duration of care. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have a care plan from home health R10, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy of R10's completed home health care plan/agreement that meets this regulation by POC due date 10/18/24.

Type B

Section Cited

CCR

87632(a)(4)

(4) A statement by the licensee that an agreement with the hospice agency will be entered into regarding the care plan for the terminally ill resident to be accepted and/or retained in the facility. The agreement with hospice shall design and provide for the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the licensee. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have a written agreement or Hospice Care plan for any residents on hospice including R5 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Licensee agrees to have proof of an agreement with hospice and hospice care plans and will submit a copy for R5 by POC due date 10/18/24.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Shawna Doucette LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Link to Parent Document Below:

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type B

Section Cited

CCR

87633(a)(2)

(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have care plans, staff training, hospice notes from visits updating care which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit a copy of R7 and R8's hospice plan including staff training and a written statement on how this regulation will be met by POC due date 10/18/24.

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Shawna Doucette LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

Link to Parent Document Below:

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2024

Type B

Section Cited

CCR

87633(h)

(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have documentation in all resident binders that are on hospice which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Licensee agrees to create a hospice file for each resident on hospice containing all required hospice documents by POC due date 10/15/24.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Sergiy Pidgirny LICENSING EVALUATOR NAME: Shawna Doucette LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
	VISIT DATE: 10/10/2024