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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209516
Report Date: 06/24/2025
Date Signed: 06/30/2025 09:08:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 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
06/17/2025 and conducted by Evaluator Sarah Hurt
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250617153822
FACILITY NAME:HIGH DESERT HAVENFACILITY NUMBER:
157209516
ADMINISTRATOR:POYTHRESS, LINDAFACILITY TYPE:
740
ADDRESS:1240 COLLEGE HEIGHTS BLVD.TELEPHONE:
(760) 371-1989
CITY:RIDGECRESTSTATE: CAZIP CODE:
93555
CAPACITY:154CENSUS: 71DATE:
06/24/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Linda PoythressTIME COMPLETED:
06:15 PM
ALLEGATION(S):
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Staff did not distribute resident's medication as prescribed
Staff did not assist resident with showering
Staff did not ensure that resident's incontinence care needs were met
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Sarah Hurt and Shawna Doucette conducted an unannounced facility visit to investigate the allegations listed above. LPA met with facility Administrator Linda Poythress, and explained the purpose of today's visit.


Regarding the allegation Staff did not distribute resident's medication as prescribed. Resident 1 was not given several doses of their medications on Friday June 13, 2025. The facility staff stated there was a miscommunication upon admission with the facilities online medication tracking system causing Resident 1's missed medication doses. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
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
Control Number 24-AS-20250617153822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209516
VISIT DATE: 06/24/2025
NARRATIVE
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Regarding the allegation Staff did not assist resident with showering. Resident 1 was not showered after having a significant bowel movement which left them with fecal matter on their back, and backside. Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation Staff did not ensure that resident's incontinence care needs were met. Resident 1 was not assisted with toileting timely. Facility pendant alert system documents Resident 1 waiting more than 30 minutes at times for assistance. Based on interviews conducted, and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiencies are being cites Per title 22 Regulations. Exit interview conducted with Administrator Linda Poythress. A copy of this report provided along with appeals rights.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20250617153822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/25/2025
Section Cited
CCR
87465(a)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. The following requirement has not been met as evidenced by:
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Administrator will conduct training with staff on resident medications upon admission and submit to LPA by POC date 06/25/2025.
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Resident 1 was not given several doses of medication on 06/13/2024, which poses an immediate, health, safety, or personal rights risk to residents in care.
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Type B
07/09/2025
Section Cited
CCR
87464(a)
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87464 Basic Services (a) The services provided by the facility shall be conducted so as to continue and promote, to the extent possible, independence and self-direction for all persons accepted for care. Such persons shall be encouraged to participate as fully as their conditions permit in daily living activities both in the facility and in the community. The following requirement has not been met as evidenced by:
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Administrator will conduct training with staff on Basic services of residents including bathing and submit to LPA by POC date of 07/09/2025.
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Resident 1 was not showered after which poses a potential, health, safety, 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: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 24-AS-20250617153822
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: HIGH DESERT HAVEN
FACILITY NUMBER: 157209516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/02/2025
Section Cited
CCR
87265(a)
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87625 Managed Incontinence(a) The licensee shall be permitted to accept or retain a resident who has a manageable bowel and/or bladder incontinence condition under the following circumstances: The following requirement has not been met as evidenced by:
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Administrator will conduct training with staff on Incontinent care of residents including bathing and submit to LPA by POC date of 07/09/2025.
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Resident 1 was not assisted timely with incontinent care, which poses a potential, health, safety, 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: Brenda Chan
LICENSING EVALUATOR NAME: Sarah Hurt
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4