366411421-7-25-2024-56-AS-MMAE-D7HUCP-20240725152817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366411421
Report Date: 07/25/2024
Date Signed: 07/25/2024 03:28:26 PM

Document Has Been Signed on 07/25/2024 03:28 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 III		FACILITY NUMBER:	366411421
ADMINISTRATOR/ DIRECTOR:	EMERSON ATIENZA		FACILITY TYPE:	735
ADDRESS:	14041 PEARL STREET		TELEPHONE:	(760) 995-3099
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 6		CENSUS: 4	DATE:	07/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:10 PM
MET WITH:	Vincent Pedroso-Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced required 1-year visit to the facility. LPA met with Vincent Pedroso, Administrator, and discussed the purpose of the visit.

LPA conducted an overall inspection of the facility, which included, but was not limited to, the following:

Operation/Physical Plant:The facility is licensed for a capacity of (6) and has a current census of a (4) ambulatory clients. The facility’s indoor and outdoor passageways were kept free of obstruction. Facility has no swimming pools or similar bodies of water. The facility has sufficient indoor and outdoor activity space for clients in care. The facility’s outdoor activity area is fenced with a self-latching gate. The facility is equipped with an operating signal system, carbon monoxide alarms and telephone service. The facility has sufficient supply of bed linen, towels, and emergency supplies for clients in care. Client bedrooms were equipped with beds, bed linen, chairs, storage space and sufficient lighting. Client bathroom equipment was operating in safe and sanitary conditions. The hot water in client bathrooms tested at 105 degrees F. The facility has 24 hour/7 days a week care staff. The facility has posted in a common area: Community Care poster, facility license, emergency telephone numbers, and facility sketch.

Food Service:The kitchen and dining areas were maintained clean. The facility has sufficient non-perishable and perishable food for number of clients in care. The facility’s freezer temperature is maintained at zero degrees. The facility’s refrigerator was maintained at 44 degrees F. Sharps, disinfectants and cleaning solutions were kept locked and store away from food areas.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

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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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: 07/25/2024

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Health Related Services: Client medications are labeled and kept centrally stored in a locked closet. The facility has complete first aid kits.

Personnel/Client Records: Staff records audited had health screenings, criminal record clearances, application records, and training certifications. Client records audited had admission’s agreements, medical assessments, needs and service plans, Personal and Incidental logs. Administrator's certification is current. Client registry and staff registry was centrally stored.

No deficiencies were cited during today's visit. An exit interview was conducted where this report was discussed and a copy provided to the Administrator at the conclusion of the visit.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC809 (FAS) - (06/04)

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