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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408344
Report Date: 04/04/2024
Date Signed: 04/04/2024 02:20:58 PM

Document Has Been Signed on 04/04/2024 02:20 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SWEET HAVEN IIFACILITY NUMBER:
366408344
ADMINISTRATOR:EMERSON ATIENZAFACILITY TYPE:
735
ADDRESS:9385 7TH AVENUETELEPHONE:
(760) 262-5933
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 4DATE:
04/04/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:05 PM
MET WITH:Zosimo Paulino - AdministratorTIME COMPLETED:
02:23 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Anna Fannell and Javier Prieto conducted an unannounced visit to deliver amended report on complaint control number: 56-AS-20231106083210. LPA Amy Goldenberg originally delivered the complaint allegation finding on 11/07/2024. LPAs Fannell and Prieto met with Zosimo Paulino and was informed of the reason for the visit.

Findings for the allegation Facility failed to report client assault to CCL and/or responsible party remain as UNSUBSTANTIATED.

The report was discussed with Administrator Paulino and copies of this report and amended findings (LIC9099) were provided at the conclusion of today’s visit.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Fannell
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2024
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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