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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881032
Report Date: 02/09/2022
Date Signed: 02/09/2022 04:07:21 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: 6DATE:
02/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:56 PM
MET WITH:Sophia Fuller, staffTIME COMPLETED:
04:10 PM
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Licensing Program Analyst (LPA) Anna Bueno made an unannounced visit to the facility to conduct an annual inspection with an emphasis on infection control. LPA was met by staff Sophia Fuller who phoned administrator Carina Davis and made them aware of the reason for the visit. There are currently 6 residents in care at the facility.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed Community Care Licensing and Covid-19 signages posted in the facility. LPA observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and proper use of face coverings. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has a plan in place which follows Community Care Licensing guidelines for when and how long to test staff and residents for COVID-19 and when and how to isolate/quarantine residents. The facility follows a daily schedule for cleaning and disinfection times of high traffic and frequently touched areas. The facility continues to monitor residents for any changes in condition and to subsequently notify the resident's physician and all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

Based on the observations made during today’s visit, there were no deficiencies cited per Title 22, Division 6, of the California Code or Regulations. An exit interview to review this report was conducted and a copy of this report was provided to the staff Sophia Fuller.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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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