High Desert Haven

Allegation investigated: Facility charged resident's bank account without authorization

On 5/13/26 Licensing Program Analysts (LPAs) M. Medina and M. Garza arrived at the facility for an unannounced complaint visit. LPAs met with Activities Director, Taylor Lloyd and Wellness Director, Elizabeth Vasku to conduct visit. During visit LPAs conducted interviews, requested and received the following documents for R1: medical assessment, pre-admission appraisal, admission agreement, ALW paperwork and ACH paperwork. During interviews, R1 indicated that they received their bank statement and saw charges from the facility and notified the bank of possible unauthorized charges. R1 stated that they then reviewed their bank statements from previous months and realized the charges are for their responsible portion of monthly rent. R1 stated they provided a voided check to facility during admission to facility. R1 also acknowledged that the initials on the Authorization Agreement for Direct Deposit Payments form for ACH debits was their signature. This Department has found that the abothe state’s words, verbatim · CDSS document, May 13, 2026 · control 24-AS-20260512144042

Allegation investigated: Staff are not addressing pests at facility Staff did not prevent resident from smoking while residents use oxygen Staff do not maintain facility in good repair Staff do not ensure that residents care needs are met Facility smells malodorous

On 5/13/26 Licensing Program Analysts (LPAs) M. Medina and M. Garza arrived at the facility for an unannounced complaint visit. LPAs met with Activities Director, Taylor Lloyd who contacted, Administrator Brittany Kavanaugh by telephone to advise of complaint visit. Wellness Director, Elizabeth Vasku arrived a short time later ton also conduct visit. Residents were observed in common areas and in their rooms. During subsequent visit, LPAs conducted additional interviews. Facility provided documentation showing pest control provided treatment in two phases, conducted 2 weeks apart for resident 1's (R1s) room. Facility provided documentation of occurrences with R1 for smoking in unauthorized areas. R1 was provided redirection to the designated smoking area and resident signed acknowledgement for resident smoking policy. Facility had an incident on 4/16/26, for a smell of burning in facility. The fire department was dispatched and facility was cleared with no fires. Invoice provided fromthe state’s words, verbatim · CDSS document, May 13, 2026 · control 24-AS-20260421083453

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility washers and dryers are in disrepair

On 4/29/2026, Licensing Program Analysts (LPAs) M. Medina and M. Garza conducted an unannounced subsequent complaint visit to facility. LPAs introduced themselves and stated purpose of visit, LPAs met with Administrator, Brittany Kavanaugh via telephone and gave permission for visit to be completed with Wellness Director, Elizabeth Vasku. During visits LPAs toured facility, completed interviews, requested and reviewed documentation (staff schedules, resident roster, invoices, staff training records). During facility tour on 4/11/2026, LPAs observed the following in the assisted living building, 2 washers and 1 dryer that were inoperable, in the memory care building of the facility 1 washer and 1 dryer that were inoperable. The allegation listed above have met the preponderance of evidence standard per California Code of Regulations, Title 22. The allegations are SUBSTANTIATED.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 24-AS-20260403093954

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure to provide resident's transportation to doctor appointments Staff does not follow activities calendar

Licensing Program Analyst Shawna Doucette met with Administrator at the Fresno Regional Office to deliver findings. LPA met with Administrator Brittany Kavanaugh and Wellness Director Elizabeth Vasku and Licensee Ben Berkowitz (Teams). During the course of the investigation, LPA conducted a facility tour, reviewed records, and conducted interviews. Interviews conducted with residents revealed that R1 missed two doctor appointments between August and September 2025 and R2 missed a doctor appointment on 11/19/2025 due to transportation staff not being present. Upon review of S1’s personnel file, LPA discovered that S1 was released from employment due to S1’s failure to transport residents to their scheduled appointments. Substantiatedthe state’s words, verbatim · CDSS document, Jan 27, 2026 · control 24-AS-20251110182020

Allegation investigated: Licensee did not follow proper eviction procedures for resident.

Licensing Program Analyst Shawna Doucette met with Administrator at the Fresno Regional Office to deliver findings. LPA met with Administrator Brittany Kavanaugh and Wellness Director Elizabeth Vasku. Licensee Ben Berkowitz. During the course of the investigation, LPA conducted interviews and reviewed records. Upon review of records, it was found that R1 was admitted to the hospital on 11/4/2025 due to behavioral issues at the facility. Hospital staff attempted to discharge R1 to the facility on the same date, however discharge was unsuccessful. Hospital staff contacted the Ombudsman, who assisted R1 in returning to the facility. R1 was discharged and transferred back to the facility on 11/21/2025. Based on interviews conducted and records review, the allegation: Licensee did not follow proper eviction procedures for resident is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did notthe state’s words, verbatim · CDSS document, Jan 27, 2026 · control 24-AS-20251112135800

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are transporting residents while under the influence, impairing their ability to provide adequate care and supervision

Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to deliver complaint findings. LPA's met with Staff Danielle Mouw. LPA's interviewed staff and residents. Interviews revealed that staff have never seen S1 using drugs or alcohol at the facility. It is unknown if staff are transporting residents while under the influence, impairing the ability to provide adequate care and supervision. Based on interviews, 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 10, 2025 · control 24-AS-20251119091440

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Resident ingested another residents medication due to staff leaving medication accessible to other residents in care

Licensing Program Analysts (LPAs) Daiquiri Boyd and Shawna Doucette conducted the 10 Day complaint investigation visit to the facility. During the course of this complaint investigation visit, LPAs interviewed staff and obtained and/or reviewed resident and facility records. It was determined based on the Incident Report submitted by the facility and records review that the above allegation is SUBSTANTIATED. Facility staff left medication accessible, allowing a resident (R1) access to another residents (R2) medications, and as a result R1 then injested medication that was prescribed for R2, requiring medical attention for R1. Based on LPAs records review and submitted reports, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Substantiatedthe state’s words, verbatim · CDSS document, Sep 3, 2025 · control 24-AS-20250825180500

Allegation investigated: Staff does not ensure resident is spoken to in an appropriate manner Staff do not ensure residents room is kept in clean sanitary conditions Staff does not ensure residents dietary plan is followed Staff does not ensure food being served is of good quality Staff does not ensure residents personal hygiene needs are being met Facility did not replace residents personal property due to being damaged

Licensing Program Analysts LPA’s Shawna Doucette and Daiquiri Boyd arrived at the facility unannounced to investigate and deliver complaint findings. LPA’s met with Wellness Director Elizabeth Vasku. LPA's reviewed records and conducted interviews. Regarding the allegation Staff does not ensure resident is spoken to in an appropriate manner Based on staff interviews and resident interviews there were no witnesses to staff speaking inappropriately to a resident. Regarding allegation Staff do not ensure residents room is kept in clean sanitary conditions. Based on facility tour, LPA's observed several resident rooms to be clean. Based on staff interviews R1 often refuses to allow staff to clean R1's room. Based on resident interviews staff are cleaning rooms frequently, as allowed by residents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 3, 2025 · control 24-AS-20250902145755

Allegation investigated: 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

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. Substantiatedthe state’s words, verbatim · CDSS document, Aug 6, 2025 · control 24-AS-20250625124618

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure temperature of food served to resident was appropriate, resulting in resident sustaining multiple burns. Staff threatened resident.

Licensing Program Analysts (LPAs) Shawna Doucette and Daiquiri Boyd arrived at the facility 09/03/2025 to amend documents previously signed. Licensing Program Analysts LPA’s Shawna Doucette and Sarah Hurt arrived at the facility on 0716/2025 unannounced to deliver complaint findings. LPA’s met with Administrator Linda Poythress. LPA interviewed residents and staff. LPA reviewed medical records. Based on medical records review and interviews, it is undetermined whether staff did or did not ensure the food served to residents was at an appropriate temperature, resulting in resident sustaining multiple burns. Medical records did not indicate resident sustained any burns. Based on interviews, it is undetermined if staff threatened a resident. Through interviews conducted, LPA did not find any evidence of threatening statements being made to any residents. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 16, 2025 · control 24-AS-20250620164716

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: 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

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. Substantiatedthe state’s words, verbatim · CDSS document, Jun 24, 2025 · control 24-AS-20250617153822

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.