366408344-10-9-2023-56-AS-RNIS-CWFQAG-20231009115955

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366408344
Report Date: 10/09/2023
Date Signed: 10/09/2023 12:00:02 PM

Document Has Been Signed on 10/09/2023 12:00 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME:	SWEET HAVEN II		FACILITY NUMBER:	366408344
ADMINISTRATOR:	EMERSON ATIENZA		FACILITY TYPE:	735
ADDRESS:	9385 7TH AVENUE		TELEPHONE:	(909) 641-8579
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 6		CENSUS: 4	DATE:	10/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:22 AM
MET WITH:	Robert Castillones and Zosimo Paulino, administrators		TIME COMPLETED:	12:07 PM

NARRATIVE

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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to complete a comprehensive annual inspection. LPA Nickolas met with administrator Robert Castillones and explained the purpose of the visit, co administrator Zosimo Paulino would later arrive at the facility. Today’s inspection included a facility tour, record review, and an interview with staff.

The facility has five (5) bedrooms and five (5) bathrooms, of which four (4) bedrooms and four (4) bathrooms are used for residents in care. The facility also has living room, family room, two (2) dining areas, two (2) kitchens, medication room, covered patio, and attached garage. Licensed capacity is six (6), with a current census of four (4).

Physical Plant: There are no obstructions to indoor and outdoor passageways. The facility temperature is 76 degrees. LPA inspected resident bedrooms; each room included required furniture such as mattresses, nightstands, storage space, and sufficient lighting; bathrooms were clean, and appliances were functional. LPA Nickolas' observed adequate furniture and lighting throughout the facility. The hot water temperature tested within regulation at 105-108 degrees Fahrenheit. The facility has operating smoke detectors and carbon monoxide alarms, which LPA Nickolas tested during the visit. The facility has two (2) charged fire extinguishers that is serviced by Hi Desert Fire. LPA Nickolas observed that most cleaning supplies, toxins, sharps, and other dangerous items are kept secure and inaccessible to residents in care. There was a designated storage space for client/staff files. LPA Nickolas observed medications locked and inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient in number for residents in care. The facility has a variety of food available for clients. Dishes, cups, and utensils were also appropriately stored.

Care & Supervision: The facility staff is sufficient in number for the care and supervision of residents in care. All staff members working in the facility have criminal record clearance through the department.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SWEET HAVEN II	FACILITY NUMBER: 366408344
	VISIT DATE: 10/09/2023

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Record Review: LPA Nickolas reviewed four (4) resident files for admission agreements, updated physician reports, needs and services plans, and audited medication for all residents. LPA Nickolas reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings.

During today’s inspection, LPA Nickolas observed a spray bottle of Clorox bleach unsecured underneath the kitchen #1 (K1) sink.

Based on observations made during today’s inspection, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations (CCR).

An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights, were provided.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/09/2023 12:00 PM - It Cannot Be Edited

Created By: Rayshaun Nickolas On 10/09/2023 at 11:41 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: SWEET HAVEN II	FACILITY NUMBER: 366408344
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(g)

Building and Grounds

(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation tthe licensee did not comply with the section cited above by ensuring that the bottle of clorox bleach spray was secured and inaccessible to residents, which poses a potential, health, safety and personal rights violation to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	The Licensee shall read the above cited sections of regulations and train all staff. Licensee shall notify the Regional Office (RO) that the training is completed for all staff by the POC due date of 10/16/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Karen Clemons

LICENSING EVALUATOR NAME:

Rayshaun Nickolas

LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023

LIC809 (FAS) - (06/04)

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