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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209068
Report Date: 12/11/2024
Date Signed: 12/12/2024 08:59:23 AM

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
12/06/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20241206091140
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: 73DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Linda PoythressTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff did not provide a copy of the admission agreement to authorized representative
Staff did not refund authorized representative
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette conducted a visit to commence a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Administrator Linda Poythress.

LPA requested a copy of R1's file. LPA interviewed staff. LPA reviewed R1's file.

Based on interviews, texts messages and records review, staff did not provide a copy of the admissions agreement to authorized representative. LPA reviewed text messages between facility Care Coordinator and authorized representative requesting copies of signed agreement with no response from facility Care Coordinator. LPA reviewed Admissions Agreement, which was signed but only partially filled out not listing R1's monthly rent.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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
12/06/2024 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20241206091140

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: 73DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Linda PoythressTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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Staff are not meeting resident's hygiene needs
Staff are not ensuring resident's hearing aides are charged
Staff are not assisting resident to bed
Staff do not answer residents calls for assistance timely
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette conducted a visit to commence a complaint investigation. LPA identified herself and discussed the purpose of the visit and the elements of the allegations with Administrator Linda Poythress.

LPA reviewed records.

Based on records review and interviews, it is unknown if staff are meeting residents hygiene needs, ensuring hearing aides are charged and assisting resident to bed. LPA reviewed records that indicate R1 had a shower on 10/28/24. LPA reviewed R1's LIC 602, which indicates R1 is able to toilet, feed, bathe and dress. LIC 602 indicates R1 can transfer to bed. LPA reviewed a text message from R1's authorized representative to facility Care Coordinator requesting to re-evaluate R1 due to the previous caregiver stating he needs assistance with ADL's.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
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-20241206091140
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: 12/11/2024
NARRATIVE
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Based on interviews, LPA was unable to determine if staff are responding to calls in a timely manner. LPA was unable to review the call log due to the USB being removed that records the information.


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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20241206091140
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: 12/11/2024
NARRATIVE
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Based on interviews and records review, facility did not refund R1's authorized representative. Administrator contacted the facility's accounting department and was advised the refund check was not issued or mailed to the authorized representative. Per Admissions Agreement if a resident is at the facility for less than 30 days 80 percent of the balance after the initial 500 dollars is deducted will be refunded. R1 resided in the facility for 6 days.

Based on record review, text messages, 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.

An exit interview was conducted 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: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20241206091140
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: 12/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/18/2024
Section Cited
CCR
87507(e)
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87507 Admission Agreements
(e) The licensee shall provide a copy of the signed and dated current admission agreement, and all subsequent signed and dated modifications, to the resident or the resident's representative, if any,
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Licensee agrees to submit a written understanding how how facility will ensure this regulation is met by POC due date 12/13/24
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immediately upon signing the admission agreement or modification. The licensee shall provide additional copies to the resident or resident’s representative upon request. This requirement was not met as evidenced by: Licensee did not complete admissions agreement and provide a copy or respond to authorized representative when authorized representative requested a copy via text which poses a potential health safety and or personal rights risk to residents in care.
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Type B
12/18/2024
Section Cited
CCR
87507(E)2.a.
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(E) Preadmission fees shall be refunded according to the following conditions: 2. Unless Section 87507(g)(5)(E)1. applies, paid preadmission fees that are greater than five hundred dollars ($500) shall be refunded to an applicant, resident, or the applicant/resident’s representative in the following manner:
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Licensee agrees to submit proof of refund to Licensing by POC due date 12/18/24.
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a. A refund of at least 80 percent of the preadmission fee in excess of $500 shall be provided if the applicant does not enter the facility after a preadmission appraisal is conducted, or the resident leaves the facility for any reason during the first month of residency. This requirement was not met as evidenced by Licensee did not refund R1's authorized representative after R1 moved only residing in the facility for 6 days which poses a potential health safety and 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: 12/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5