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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336409085
Report Date: 05/04/2022
Date Signed: 05/04/2022 12:24:04 PM


Document Has Been Signed on 05/04/2022 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:HILLTOP GUEST HOMEFACILITY NUMBER:
336409085
ADMINISTRATOR:MARISSA MASHBURNFACILITY TYPE:
740
ADDRESS:30951 BLACKHORSE DRIVETELEPHONE:
(951) 244-6837
CITY:CANYON LAKESTATE: CAZIP CODE:
92587
CAPACITY:6CENSUS: 4DATE:
05/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Christopher Bundalian, AdministratorTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Javina George made an unannounced visit to conduct a case management visit to follow up on a client's death. LPA met with Administrator Christopher Bundalian and explained the purpose of today's visit. LPA was informed that Client#1( C1) was discharged from the facility on 04/07/22, due to requiring a higher level of care.

During the visit LPA reviewed and collected pertinent documentation such as: ID/Emergency information, Admission Agreement, Psychiatric and Medical notes/orders, Medication records, Weight record as well as conducted staff interviews in regards to the death of C1. LPA interviewed Administrator for further information in regards to the death of C1 and the events that led up to C1's death.

LPA inquired about the cause of the death. A death certificate has not been issued at this time. Additionally, the preliminary cause of death is still being determined. LPA advised to send a copy of the death certificate to the regional office once received.

No deficiencies were cited during this visit, or health and safety concerns were observed.

An exit interview was conducted, a copy of this report, and confidential names list (LIC811) was provided to Administrator Christopher Bundalian.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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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