<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 02/04/2025
Date Signed: 02/04/2025 01:31:30 PM

Document Has Been Signed on 02/04/2025 01:31 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/
DIRECTOR:		MATHEW, ABRAHAMFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVDTELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY: 82CENSUS: 70DATE:
02/04/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:37 AM
MET WITH:Administrator Linda PoythressTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA)'s Shawna Doucette and Melinda Medina responded to the facility to conduct a Case Management for two incidents that occurred. LPA's met with Administrator Linda Poythress.


LPA's did not tour the facility due to an outbreak of scabies. Rash started July 2024. LPA did not receive incident report from facility regarding rash until 1/20/25. LPA received a second incident report with rash diagnosis of scabies on 2/3/24.

LPA's obtained files for the second incident. LPA will review files for R1 and R2 regarding physical abuse between R1 and R2. LPA will return at a later date to issue citation if warranted.


See attached 809D.

A copy of this report was provided to Administrator with plan of correction and appeal rights. Civil penalty for repeat violation was issued.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/04/2025
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 02/04/2025 01:31 PM - It Cannot Be Edited


Created By: Shawna Doucette On 02/04/2025 at 12:46 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: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/21/2025
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
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
1
2
3
4
5
6
7
Plan of Correction Licensee agrees to conduct staff training on reporting requirements. Licensee will submit agenda of training and staff signatures that receive the training by POC due date 02/21/24.
8
9
10
11
12
13
14
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. Based on interviews, facility did not report rash that started in 7/24, which poses and i
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/04/2025


LIC809 (FAS) - (06/04)
Page: 2 of 2