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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
157209068
Report Date:
03/01/2022
Date Signed:
03/01/2022 07:18:02 PM
Document Has Been Signed on
03/01/2022 07:18 PM
- 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 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:
6
DATE:
03/01/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
06:16 PM
MET WITH:
Resdential Care Coordinator, Carolyn Sorruste
TIME COMPLETED:
07:30 PM
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On 03/01/22, Licensing Program Analysts (LPAs) L. Salazar and S. Doucette arrived at the facility unannounced to obtain requested records from earlier today.
Exit interview conducted.
SUPERVISOR'S NAME:
Melinda Hoffmann
TELEPHONE:
(559) -65-7914
LICENSING EVALUATOR NAME:
Lisa Salazar
TELEPHONE:
(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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