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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209068
Report Date: 03/26/2025
Date Signed: 03/26/2025 03:40:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
02/03/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20250203125915
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: 75DATE:
03/26/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Linda PoythressTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident sustained multiple unexplained injuries while in care
Resident sustained multiple falls due to lack of supervision
Facility staff left resident lying on the floor
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette and K.Kaur arrived at the facility unannounced to conduct a subsequent investigation regarding the allegations listed above. LPA(s) was granted into the facility by the Administrator. LPA(s) met with Administrator Linda Poythress.

LPA reviewed facility records and medical records. LPA interviewed staff and witnesses. LPA reviewed submitted videos and photos.

Based on facility records review, medical records review, and photos, R1 had sustained multiple unexplained injuries. Review of photos and medical records R1 had multple visible injuries with no documentation of how the injuries occurred. Facility submitted an incident report on 09/20/24, however there were no other incident reports submitted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 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
02/03/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20250203125915

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: 75DATE:
03/26/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Linda PoythressTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Facility staff handled resident in a rough manner
Facility staff spoke inappropriately to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Doucette and K.Kaur arrived at the facility unannounced to conduct a subsequent investigation regarding the allegations listed above. LPA(s) was granted into the facility by the Administrator. LPA(s) met with Administrator Linda Poythress.

The Department investigated the allegations Facility staff handled resident in a rough manneand staff speaking inappropriately to resident. Based on interviews conducted and records reviewed, there were no instances that were recorded of staff speaking inappropriately to resident or staff handling a resident in a rough manner. 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 with Administrator Linda Poythress and a copy of this report was provided, whose signature on this form confirms receipt of this document.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
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 4
Control Number 24-AS-20250203125915
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209068
VISIT DATE: 03/26/2025
NARRATIVE
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Based on interviews and records review, resident sustained multiple falls due to lack of supervision. After conducting interviews with staff and responsible parties R1 had a private caregiver that came a few hours a day to assist R1. Facility did not have a written care plan to address R1's frequent falls. Facility notes stated R1 is falling approximately 8 times a day.

Based on video dated 12-20-24, R1 was left on the floor for at least 40 minutes before staff assisted him.

Based on interviews, records review, observation, videos and photos, 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: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20250203125915
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209068
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/27/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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Licensee agrees submit plan to obtain electronic charting system for daily charting and will set up an email procedure for end of shift reporting by POC due date 03/27/25
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Licensee did not have a care plan regarding R1's falls and R1 had multiple unexplained injuries with no documentation on how the injuries occurred which poses an immediate health safety and or personal rights risk to residents in care.
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Type A
03/27/2025
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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Licensee conducted a training on personal rights and will submit copies of training by POC due date 03/27/25
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This requirement was not met as evidenced by: Licensee did not ensure R1 was treated with dignity by leaving R1 on the floor for 40 minutes, which poses and 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: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4