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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157209516
Report Date: 08/06/2025
Date Signed: 08/06/2025 08:43:50 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
06/25/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20250625124618
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: 69DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator Linda PoythressTIME COMPLETED:
08:45 PM
ALLEGATION(S):
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7
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9
Staff neglect resulted in a resident sustaining multiple pressure injuries
Staff do not meet the needs of residents diagnosed with a restricted health condition
Staff do not provide adequate care and supervision of the residents
Staff are not following proper reporting requirements
Staff are mishandling the residents medications
INVESTIGATION FINDINGS:
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7
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13
Licensing Program Analysts LPA’s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to investigate and deliver complaint findings. LPA’s met with Administrator Linda Poythress.

LPA's conducted interviews and reviewed records.

Regarding the allegation Staff neglect resulted in a resident sustaining multiple pressure injuries: Based on records review and interviews, during visit on 06/27/25 R7 did not have a Hospice Care Plan. LPA's Sarah Hurt and Shawna Doucette returned on 08/6/25 and R7 has a Hospice Care plan, which does not address the stage of R7's wound or that R7 has a wound and staff responsibilities. Hospice care plan states R7 needs to be turned/repostioned every 2 hours. Hospice Care Plan does not state staff were trained on repositioning/turning R7, however R7 is not bedridden. Staff interviews indicate R7 does have a wound.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
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 7
Control Number 24-AS-20250625124618
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: 157209516
VISIT DATE: 08/06/2025
NARRATIVE
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Regarding the allegation Staff do not meet the needs of residents diagnosed with a restricted health condition: Based on interviews and records reviews, R2 does not have a Home Health Care Plan. Based on interviews Staff are draining catheter bag without training from Home Health. Staff are cleaning the insertion area of the catheter. Facility does not have a restricted health care plan for R8's restricted health condition or staff training.

Regarding the allegation Staff do not provide adequate care and supervision of the residents: Based on records review and interview, facility staff did not respond to change feces soiled brief for R1 for several hours. After conducting staff interviews facility staff stated response time to call lights is 5 minutes. After review of records of call light system for June 18, 2025 to June 25, 2025 several were over 15 minutes to 1 hour and 45 minutes.

Regarding the allegation Staff are not following proper reporting requirements. Resident 1, and resident 4 were not given prescribed medication for multiple days during the month of June 2025. Facility staff did not report the missed medication to Licensing as required.

Regarding the allegation Staff are mishandling the residents medications. Resident 1 and Resident 4 missed multiple prescribed medications during the month of June 2025. No reason was documented as to why medications were not being administered to residents. R4 should have had a medication administered at 8 PM and did not get the medication until 10:19 PM.

Based on records reviewed interviews and observation for the allegations preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

A copy of this report with plans of correction and appeal rights were provided.


SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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
06/25/2025 and conducted by Evaluator Shawna Doucette
COMPLAINT CONTROL NUMBER: 24-AS-20250625124618

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: 69DATE:
08/06/2025
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Wellness Director, Elizabeth VaskuTIME COMPLETED:
08:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not following infection control requirements
Staff do not ensure the facility is free from disrepair
Staff do not provide transportation service for the residents
Staff denied a resident access to food
INVESTIGATION FINDINGS:
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Licensing Program Analysts LPA’s Shawna Doucette and Daiquiri Boyd responded to the facility on 9/3/2025 to amend the report. LPA's met with Wellness Director Elizabeth Vasku.
On 8/6/2025, Licensing Program Analysts LPA’s Shawna Doucette and Sarah Hurt arrived at the facility unannounced to investigate and deliver complaint findings. LPA’s met with Administrator Linda Poythress.

LPA's reviewed records and conducted interviews.

Regarding the allegation Staff are not following infection control requirements. Based on staff interviews and observation the facility staff is using proper PPE and following infection control plan when assisting R9 with treatment. Facility has a current infection control plan.

Regarding allegation Staff do not ensure the facility is free from disrepair. Based on LPA’s observation during Post Licensing visit on 07/16/2025, LPA's did not observe the facility to be in disrepair.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 24-AS-20250625124618
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: 157209516
VISIT DATE: 08/06/2025
NARRATIVE
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3
4
5
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Regarding the allegation Staff do not provide transportation service for the residents. Based on interviews, R1 chose to lay on the floor and did not fall. R1 did not want to be transported.


Regarding the allegation Staff denied a resident access to food. Based on staff interviews, and observation Resident R1 is being offered food daily. LPA’s interviewed three facility staff who all stated R1 is declining food and not currently eating regularly. Resident R1 is currently on hospice due to rapid health decline. LPA’s observed caregiver bringing dinner tray to Resident R1 during visit.


Although the allegations listed may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.


A copy of this report was provided.
SUPERVISORS NAME: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 24-AS-20250625124618
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: 157209516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2025
Section Cited
CCR
87465(a)(4)
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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:
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Plan of Correction: Licensee agrees to submit a plan indicating the date and source of medication training and submit by POC due date 08/07/25
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(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met by R1 and R4 not receiving several medications in the month of June 2025, which poses and immediate health safety and personal rights risk to residents in care.
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Type A
08/07/2025
Section Cited
CCR
87609(4)
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(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident’s medical condition(s).
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The Licensee agrees to submit a of a home health care plan for R8 due to R2 no longer residing at the facility by 08/7/25
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THie requirement was not met as evidenced by Licensee did not have a Home Health Care Plan or staff training for R2's restricted health condition and straff are cleaning the insertion area of the restricted health condition and R8 does not have a restricted Health Care Plan for R8's restricted health condition, which poses an 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: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 24-AS-20250625124618
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: 157209516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2025
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 ection 1569.2(c). This requirement was not met as evidenced by: Licensee did
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Licensee agrees to submit a written plan on how care and supervision needs will be met by POC due date 08/07/25
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not meet R1's inontinence needs and staff not responding to call lights within in a timely manner on several days in the month of June 2025 ranging from 15 minute to 1 hour 45 minutes which poses an immediate health safety and personal rights to residents in care.
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Type B
08/12/2025
Section Cited
CCR
87633(a)
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(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility when all of the following conditions are met:
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Plan Of Correction Licensee agrees to obtain a complete hospice care plan for R7 by POC due date 08/12/25.
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(4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s). This requirement was not met as evidenced by R7 not having a Hospice Care Plan indicating care needed 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: Alexandria Walton
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 24-AS-20250625124618
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: 157209516
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2025
Section Cited
CCR
87211(a)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee agrees to submit in writing a plan on how this regulation will be met by POC due date 08/12/25
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This requirement was not met as evidenced by Licensee did not report R1 and R4's missed medications which poses a potential 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: 08/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7