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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 10/10/2024
Date Signed: 10/10/2024 06:07:05 PM

Document Has Been Signed on 10/10/2024 06:07 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/
DIRECTOR:		MATHEW, ABRAHAMFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVDTELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY: 82CENSUS: 73DATE:
10/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Administrator Linda PoythressTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On 10/10/2024 LPAs B. Miranda & S. Doucette arrived to the facility unannounced to conduct a case management visit regarding an incident that occurred on 9/18/24. LPAs met with Administrator Linda Poythress.

LPAs reviewed R3's file and found R3 was sent out to the hospital on 9/18/24 & 9/19/24. An incident report was submitted to the Dept informing resident was sent to the hospital on 9/18/24 only. R3 being sent to the hospital on 9/19/24 was not reported to the Dept.

LPAs also reviewed medication which show R1 missed Vitamin D3 from 10/5/24-10/10/24. S2 could not provided verification documenting the missed medication and the medication error was not reported to the Dept.

The is a repeat violation. Citation will be issued under Title 22, and civil penalty will be issued.

Exit interview was conducted, copy of report LIC809, LIC809D, and LIC421FC were provided to Administrator Linda Poythress.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Brianna Miranda
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
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 10/10/2024 06:07 PM - It Cannot Be Edited


Created By: Brianna Miranda On 10/10/2024 at 05:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209068

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2024
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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Staff will report incidents to Administrator, and Administrator will submit reports to the Department.
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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 reviewed R3's records which indicated R3 was sent to the hospital on 9/19/24 and was not reported to the Dept. LPAs checked R1's medication records which showed medication errors which were no reported to the Dept.
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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 Chan
LICENSING EVALUATOR NAME:Brianna Miranda
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


LIC809 (FAS) - (06/04)
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