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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209068
Report Date: 09/16/2024
Date Signed: 09/16/2024 07:55:57 PM

Substantiated


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
09/11/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240911100801
FACILITY NAME:HIGH DESERT HAVENFACILITY NUMBER:
157209068
ADMINISTRATOR:MATHEW, ABRAHAMFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVDTELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:82CENSUS: 77DATE:
09/16/2024
UNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Administrator Linda Poythress TIME COMPLETED:
08:00 PM
ALLEGATION(S):
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Staff mismanage residents' medication(s).
Uncleared staff worked at the facility.
Staff do not safeguard residents' personal possessions.
Staff speak inappropriately to resident(s) in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette and Brianna Miranda conducted a visit to commence a complaint investigation. LPA's identified themselves and discussed the purpose of the visit and the elements of the allegations with Administrator Linda Poythress.

LPA's toured the facility, obtained copies of the staff schedule, and interviewed staff and residents.

Based on records review and interviews, R1's centrally stored log showed a log of 29 pills, however the pill bottle showed an amount of 90 pills.
Based on records review in LIS and Guardian, S2, S3 and S4 are not fingerprint cleared in the system. S2 and S3 were working during the time of the visit. S4 was not present, but has been working at the facility for about 2 weeks.
Based on interviews, staff are using other residents belongings for another resident if a resident runs out of incontinence supplies.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
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 5
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
09/11/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20240911100801

FACILITY NAME:HIGH DESERT HAVENFACILITY NUMBER:
157209068
ADMINISTRATOR:MATHEW, ABRAHAMFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVDTELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:82CENSUS: 77DATE:
09/16/2024
UNANNOUNCEDTIME BEGAN:
11:13 AM
MET WITH:Administrator Linda Poythress TIME COMPLETED:
08:00 PM
ALLEGATION(S):
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9
Staff do not ensure that residents are provided a sufficient amount of liquids while in care.
Staff do not prevent resident from harming other resident(s) in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette and Brianna Miranda conducted a visit to commence a complaint investigation. LPA's identified themselves and discussed the purpose of the visit and the elements of the allegations with Administrator Linda Poythress.

LPA's interviewed staff, residents and reviewed records.

Based on observation and interviews, LPA's observed water with cups in the activities room and juice in the dining area accessible to residents.
Based on interviews, it is unknown if staff do not prevent a resident from harming another resident in care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted and a copy of this report was provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
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 5
Control Number 24-AS-20240911100801
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: 09/16/2024
NARRATIVE
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Based on interviews, Staff do not speak appropriately to residents in care. LPA conducted multiple interviews and multiple interviewees stated S5 speaks inappropriately to residents in care.

Based on record review and interviews, the preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. Civil Penalties were issued.

An exit interview was conducted with Administrator and a copy of this report along with appeal rights and plan of correction were provided.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20240911100801
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
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POC Licensee agrees to conduct a staff training for medication technicians by POC due date 09/25/24.
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(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by Licensee did not log a start date for R1's medication and showed a total of 29 pills on the centrally stored log however the bottle stated 90 pills total, which poses an immediate health safety and personal rights risk to residents in care.
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Type A
09/17/2024
Section Cited
CCR
87355(e)(1)
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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and
afety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption
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POC Licensee agrees to submit a written statement on how this regulation will be met in the future by POC due date 09/17/24.

Civil Penalties issued. S2 and S3 were removed during visit.
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as required by the Department or This requirement was not met as evidenced by Licensee did not ensure S2, S3 and S4 were fingerprint cleared to work in the facility. S2 and S3 were present during LPA's visit and S4 had been working the past two weeks, which poses an immediate health safety and or personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20240911100801
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/25/2024
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
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POC Licensee agrees to conduct a training on personal rights and submit by POC due date 09/25/24.
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This requirement was not met as evidenced by Licensee did not ensure residents were spoken to appropriately. After conducting interviews multiple interviewees reported S5 spoke inappropriately to residents in care which poses an immediate health safety and or personal rights risk to residents in care.
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Type B
09/20/2024
Section Cited
CCR
87468.1(a)(12)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (12) To wear their own clothes; to keep and use their own personal possessions, including their toilet articles; and to keep and be allowed to spend their own money.
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POC Licensee agrees to conduct a personal rights training by POC due date 09/25/24.
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This was not met as evidenced by Licensee did not ensure residents personal property was not used for other residents which poses a potential health safety and or personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5