366411421-6-5-2025-56-AS-MMAE-DHCV5H-20250605160758

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366411421
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:08:14 PM

Document Has Been Signed on 06/05/2025 04:08 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:	VINCENT PEDROSO		FACILITY TYPE:	735
ADDRESS:	14041 PEARL STREET		TELEPHONE:	(760) 995-3099
CITY:	HESPERIA	STATE: CA	ZIP CODE:	92345
CAPACITY: 6		CENSUS: 4	DATE:	06/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Vincent Pedroso		TIME VISIT/ INSPECTION COMPLETED:	04:10 PM

NARRATIVE

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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 operating carbon monoxide/smoke alarms, fire extinguishers, signal system, covered fireplace and telephone service. Client bedrooms were equipped with beds, bed linen, chairs, storage space and lighting. Client bathroom equipment was fully operational; however, the hot water in client's upstairs bathroom tested at 95 degrees F. A deficiency cited. The facility has 24 hour/7 days a week care staff. The facility has posted in a common area: Community Care poster, facility license, and emergency telephone numbers.

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 and refrigerator has sufficient space and fully operational. Sharps, disinfectants and cleaning solutions were kept locked and store away from food areas.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 06/05/2025

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

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 (P&I). Administrator's certification is current. Client registry was centrally stored.

A deficiency is being cited per Title 22 of the California Code of Regulations. An exit interview was conducted where this report was discussed and a copy with appeal rights was provided to the Administrator at the conclusion of the visit.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Magda Malcore
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/05/2025 04:08 PM - It Cannot Be Edited

Created By: Magda Malcore On 06/05/2025 at 03:50 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: 06/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

(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
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above by hot water temperature in clients bathroom test 95 degrees F; which poses/posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/06/2025
	Plan of Correction
1 2 3 4	The Administrator stated that they will provide proof that water is within regulation to the licensing agency by POC due date.

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.

	Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:

	Magda Malcore
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025

LIC809 (FAS) - (06/04)

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