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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408344
Report Date: 10/05/2024
Date Signed: 10/05/2024 12:24:22 PM

Document Has Been Signed on 10/05/2024 12:24 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:SWEET HAVEN IIFACILITY NUMBER:
366408344
ADMINISTRATOR/
DIRECTOR:		EMERSON ATIENZAFACILITY TYPE:
735
ADDRESS:9385 7TH AVENUETELEPHONE:
(760) 262-5933
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 4DATE:
10/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Robert CastillonesTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA was granted entry into the facility by Administrator Robert Castillones and discussed the purpose of the visit. The facility is a one-story, Adult Residential facility with a license capacity of (6) and a current census (4). The facility is a certified Inland Regional Center (IRC) vendor. LPA conducted an overall inspection, which included, but was not limited to, the following:

Operation/Physical Plant: Indoor and outdoor passageways were kept free of obstruction. The facility has no swimming pools or similar bodies of water. The facility's outdoor activity space is shaded and fenced. The facility is equipped smoke/carbon monoxide alarms, fully charged fire extinguisher, laundry equipment, night lights and telephone service. The facility has sufficient supply of bed linen, towels, and hygiene products for clients in care. Client bedrooms were equipped with beds, bed linen, nightstands, chairs, storage space and lighting. Client bathroom equipment was in operating conditions. The hot water in 3 of the 4 bathrooms inspected was not maintained within regulation. Bathroom #1 tested at 122 degrees F, Bathroom #2 and bathroom #3 tested at 124 degrees F. A deficiency cited. Sharps, disinfectants, and cleaning supplies were store in a locked cabinet. The facility has posted in a common area client personal rights, facility license, menus, activities, and emergency contact numbers. The facility has an infection control and disaster plan for review.

Food Service: The dining room rug and floors were dusty and not maintained clean. A deficiency was cited. The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s refrigerator tested at 44 degrees F and had sufficient storage space.

Personnel/Client Records: Staff records were reviewed for health screenings, personnel employment history, criminal record clearances, first aid/CPR training certifications, and the Administrator's certification. Client records were reviewed for admission agreements, medical assessments, needs and service plans, and personal/incidental logs.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SWEET HAVEN II
FACILITY NUMBER: 366408344
VISIT DATE: 10/05/2024
NARRATIVE
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Health Related Services: The facility maintains records of client medications and medications are centrally stored in a locked room.

Deficiencies and technical advisories were cited in accordance with Title 22 of the California Code of Regulations. An exit interview was conducted, where this report and correction plans were discussed with the Administrator. Copies the licensing reports were provided with Appeal Rights to the Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 10/05/2024 12:24 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/05/2024 at 11:30 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
RIVERSIDE, CA 92507

FACILITY NAME: SWEET HAVEN II
FACILITY NUMBER: 366408344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above by not maintaining hot water tempertures in 3 out of 4 bathrooms within 105 t0 120 degrees; which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/07/2024
Plan of Correction
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The Licensee shall provide proof to the licensing agency that the water temperatures are with regulation by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/05/2024 12:24 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/05/2024 at 11:30 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
RIVERSIDE, CA 92507

FACILITY NAME: SWEET HAVEN II
FACILITY NUMBER: 366408344

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observations, the licensee did not comply with the section cited above not maintaining dining area floors clean; which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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The Licensee shall submit proof to the Licensing Agency of cleaned rug and floors by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2024


LIC809 (FAS) - (06/04)
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