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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881032
Report Date: 02/08/2021
Date Signed: 02/08/2021 03:53:24 PM

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:HILLSONG SENIOR LIVING AND HOSPICEFACILITY NUMBER:
361881032
ADMINISTRATOR:DAVIS, CARINA K.FACILITY TYPE:
740
ADDRESS:2434 CIENEGA DR.TELEPHONE:
(909) 232-9834
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY:6CENSUS: 0DATE:
02/08/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Carina K DavisTIME COMPLETED:
02:30 PM
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Licensing Program Analysts (LPA's) Pauline Beschorner conducted an announced pre-licensing inspection to the facility via Microsoft Teams. LPA met with Carina Davis, Licensee.

The home is a four bedroom, three bath home with a living room, dining room and kitchen. Per the approved fire clearance, the licensee is approved for 1 bedridden and 5 non-ambulatory residents. All bedrooms are furnished with bed, night stand, dresser and chair and have adequate lighting for residents use. The facility currently has linens, towels and a sufficient amount of hygiene products for residents. The bathrooms were inspected to have grab bars and non-skid mats installed for resident safety. The water temperature was not tested as licensee did not have a water thermometer to test the water. The licensee is aware that water temperature should be between 105 and 120 degrees Fahrenheit. The smoke alarms and carbon monoxide alarms were tested and are in operating order. LPA observed 2 fire extinguishers present in the facility and fully charged. The kitchen was observed to have dishes, silverware, pots and pans. LPA observed the cabinet under the sink to be locked and where the facility will store some cleaning products. LPA observed there to be 7 days of non-perishable foods. Licensee is aware that 3 days of perishable foods are needed prior to residents in care. LPA observed a menu containing at least 7 days of meals. LPA observed a locked cabinet in the hall where the medications will be kept. LPA observed the sharps to be locked in the same closet. LPA observed a complete first aid kit. The backyard was observed to be fully fenced with an unlocked gate.

An exit interview was conducted and a copy of this report was reviewed and given to Carina Davis via email.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Pauline BeschornerTELEPHONE: (951) 897-7936
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021
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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