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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157209068
Report Date: 03/01/2022
Date Signed: 03/02/2022 07:50:46 AM


Document Has Been Signed on 03/02/2022 07:50 AM - It Cannot Be Edited

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: DATE:
03/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Carolyn Sorruste, Residential Care Coordinator TIME COMPLETED:
12:45 PM
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On 03/01/2022, Licensing Program Analysts (LPAs) L. Salazar and S. Doucette arrived at the facility unannounced to follow up on the Case Management-Health & Safety inspections conducted on 02/28/22; specifically, in relation to two residents who were observed to have conditions requiring immediate medical attention and to obtain additional resident records.

LPAs were greeted by RCC and explained the reason for the visit.

LPAs conducted another tour of facility and requested copies of physician’s reports for all residents in care. LPAs stated they would return later today to allow facility time to print documents.

Exit interview was conducted with RCC.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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