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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411421
Report Date: 07/26/2023
Date Signed: 07/26/2023 03:53:55 PM

Document Has Been Signed on 07/26/2023 03:53 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 IIIFACILITY NUMBER:
366411421
ADMINISTRATOR:EMERSON ATIENZAFACILITY TYPE:
735
ADDRESS:14041 PEARL STREETTELEPHONE:
(760) 995-3099
CITY:HESPERIASTATE: CAZIP CODE:
92345
CAPACITY: 6CENSUS: 4DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Vincent Pedroso- AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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On 07/26/23, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Administrator, Vincent Pedroso and introduced self and stated the purpose of the visit. LPA was informed that there are currently 4 clients in care in which 3 are home and 1 in day program.

The facility has 4 client bedrooms, 2 client bathrooms, 1 staff bedroom, living room, kitchen, family room, 2 dining areas, laundry room, attached garage, and backyard. The facility is vendorized by Inland Regional Center. LPA completed a walk through of the facility and review of records.

Physical Plant: The facility is not operating in the capacity approved by Community Care Licensing (CCL). LPA reviewed the facility sketch that was approved by the fire inspector an observed that there has been alterations made on the current floor plan. The loft has been converted into a staff bedroom and master bedroom into a client's bedroom. Deficiency issued with civil penalty. The facility has no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 78 degrees farenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. Water temperature tested at 111.1 degrees farenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and two charged fire extinguishers. Posters such as; the personal rights, emergency disaster plan and CCL complaint poster were posted in a common area. LPA observed the Emergency disaster plan last reviewed on 06/03/2019. Technical violation issued. Cleaning supplies, toxins, sharps, medication and other dangerous items were kept locked and secured inaccessible to clients. There was a designated storage space for clients/staff files. First aid kit and emergency disaster kits were observed in the facility. There are no firearms, ammunition, pools or bodies of water in the facility.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a wide variety of food available for clients. Dishes, cups, and utensils were also stored properly.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/26/2023
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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Document Has Been Signed on 07/26/2023 03:53 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/26/2023 at 02:40 PM
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 III
FACILITY NUMBER: 366411421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80010(a)
Limitations on Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the capacity limitation.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the Licensee made alterations to the facility and does not match the approved fire inspection facilty floor plan. Staff master bedroom is now converted into client's bedroom and the loft is converted into a Staff's bedroom which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/27/2023
Plan of Correction
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Administrator stated that a LIC200 along with the facility floor plan will be submitted to the RO to request an update to fire clearance approval for the alterations made to the facility by POC due date. Administrator will email a copy to LPA by POC due 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/26/2023 03:53 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 07/26/2023 at 02:40 PM
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 III
FACILITY NUMBER: 366411421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80010(b)(1)
Limitations on Capacity and Ambulatory Status
(b) Facilities or rooms approved for ambulatory clients only shall not be used by nonambulatory clients. (1) Clients whose condition becomes nonambulatory shall not use rooms or areas restricted to ambulatory clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in having a client with a nonambulatory status in bedroom #2 which is approved for an ambulatory status which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/02/2023
Plan of Correction
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Administrator stated that there is a mistake on the physician's report and an updated physician's report will be submitted to LPA by POC due date via email.
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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023


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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: SWEET HAVEN III
FACILITY NUMBER: 366411421
VISIT DATE: 07/26/2023
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Yards/Outside: One shaded patio, and a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Record Review: LPA reviewed client files for admission agreements, updated physician reports, and needs and services plans. LPA observed that the ambulatory status for a client on the physican's report does not match the ambulatory status bedroom approved by fire inspection. Deficiency issued. LPA also reviewed Administrator's and one staff file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. Medications were audited at random. The facility last conducted an emergency drill on July 24, 2023.

One technical violation, two deficiencies and one civil penalty were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC9102TV, LIC809D, LIC421IM and appeal rights were discussed and copies were provided to the Administrator, Vincent Pedroso.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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