157209068-10-10-2021-24-AS-MHON-C7RPPN-20211013112946

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209068
Report Date: 10/06/2021
Date Signed: 10/10/2021 02:39:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2021 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20210512115201

FACILITY NAME:	HIGH DESERT HAVEN		FACILITY NUMBER:	157209068
ADMINISTRATOR:	MATHEW, ABRAHAM		FACILITY TYPE:	740
ADDRESS:	1240 COLLEGE HEIGHTS BLVD		TELEPHONE:	(760) 371-1989
CITY:	RIDGECREST	STATE: CA	ZIP CODE:	93555
CAPACITY:	82	CENSUS: 75	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Carolyn Storruste, Residential Care Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not groom resident
Staff did not bathe resident

INVESTIGATION FINDINGS:

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On 10/06/21, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegations. LPA was met my Residential Care Manager (RCM) and was allowed entry into the facility. COVID precautionary measures were taken at the time of entry.

During the course of the investigation, LPA conducted interviews with staff and conducted records review for the month of May and the daily logs that include a book for shower logs. Records review reveal the shower log book with dates of Resident R1's showers. Also listed were 3 days where R1 refused to shower and 1 day R1 did not want to get dressed due to pain . LPA observed Resident R1 in their room at the time of visit. R1 was dressed, sitting on their couch watching TV. R1 was unable to answer questions due to cognitive impairment.

(Continued on 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2021 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20210512115201

FACILITY NAME:	HIGH DESERT HAVEN		FACILITY NUMBER:	157209068
ADMINISTRATOR:	MATHEW, ABRAHAM		FACILITY TYPE:	740
ADDRESS:	1240 COLLEGE HEIGHTS BLVD		TELEPHONE:	(760) 371-1989
CITY:	RIDGECREST	STATE: CA	ZIP CODE:	93555
CAPACITY:	82	CENSUS: 75	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Carolyn Storruste, Residential Care Manager		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Licensee did not safeguard resident's property
Resident not allowed to receive phone calls
Staff not meeting resident's dietary needs
Facility not maintained clean and sanitary at all times

INVESTIGATION FINDINGS:

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On 10/06/21, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on the above allegations. LPA was met my Residential Care Manager (RCM) and allowed entry into the facility. COVID precautionary measures were taken at the time of entry.

During the course of the investigation, LPA conducted interviews with staff, records review and toured the facility. LPA observed copies of facility's theft and loss policy that was posted in the facility. LPA observed form LIC 621(Client/Resident Personal Property and valuables), that listed a TV and DVD only. Included on this form was the signature of responsible party dated 08/15/17. LPA interviews with Staff S1 revealed phone calls were made available by S1 using their personal phone. Facility requested responsible party to provide Resident R1 with a device that would allow open communication with their family, however, no device was provided.

(Continued on 9099-C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 24-AS-20210512115201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
	VISIT DATE: 10/06/2021

NARRATIVE

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(Continued from 9099)

LPA observed menus prepared by a dietician posted in the dining area. In the kitchen, LPA observed a white board for special diets. Resident R1 was not on a special diet, however, it was noted R1 did not like eggs. Records review of communication logs revealed entries where Resident R1 stated, "I'm just not hungry" or "I don't want anything." LPA reviewed weight records for R1 from January to August. R1's weight increased by 3.8 pounds. LPA observed Resident R1 in their room at the time of visit. R1 was dressed, sitting on their couch watching TV. R1 was unable to answer questions due to cognitive impairment.

Interview with staff revealed that resident R1 eats the biggest meal at lunch and will refuse dinners on some days. Staff continue to encourage resident to eat and drink water. Tour of the facility and resident's room revealed the facility and room to be free from debris and odor.

This agency has investigated the above allegations and have found that the complaint allegations are UNFOUNDED, meaning that the allegations are false, could not have happened and/or without reasonable basis. We have therefore dismissed the complaint.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 24-AS-20210512115201

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HIGH DESERT HAVEN	FACILITY NUMBER: 157209068
	VISIT DATE: 10/06/2021

NARRATIVE

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(Continued from 9099)

Interviews with staff revealed that resident R1 refuses to shower on some days and refuses due to resident's hip pain and diagnosis. Staff continue to encourages showering to resident.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur. The allegation is UNSUBSTANTIATED. No Deficiencies cited.

An exit interview was conducted with Residential Care Manager and a copy of this report was provided via email. An electronic email read receipt confirms receiving these documents.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa Salazar	TELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

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