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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 01/31/2022
Date Signed: 02/03/2022 09:27:42 AM

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:MATHEW, ABRAHAMFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVDTELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:82CENSUS: 72DATE:
01/31/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Carolyn Storruste - Residential Care ManagerTIME COMPLETED:
04:15 PM
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Licensing Program Analysts(LPA's) L. Salazar and D. Ayers arrived unannounced to conduct a Case Management visit. LPA's met with Carolyn Storruste and announced the purpose of the visit.

LPA's conducted interviews and requested documentation in regards to an incident which occurred on 12/21/2021. No deficiencies were cited during the inspection. A copy of the report was provided.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: David AyersTELEPHONE: (559) 650-7925
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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