157209068-10-10-2021-24-AS-MHON-C7XSTU-20211019141006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 157209068
Report Date: 10/06/2021
Date Signed: 10/10/2021 03:11:53 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
07/30/2021 and conducted by Evaluator Lisa Salazar

COMPLAINT CONTROL NUMBER: 24-AS-20210730144004

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:	01:05 PM
MET WITH:	Carolyn Storruste, Residential Care Manager (RCM)		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is retaliating against resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 and conducted record review of Resident R1's Eviction Letter, Appraisal and Needs Service Plan (LIC625) and a current Physician's report (LIC602a) signed and dated 07/07/21. Records revealed a change of condition from the time of R1's admission, which requires a higher level of care that the facility cannot provide at this time.

This agency has investigated the above allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur. The allegation is UNSUBSTANTIATED.

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.

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 1