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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881032
Report Date: 02/12/2024
Date Signed: 02/12/2024 02:13:43 PM


Document Has Been Signed on 02/12/2024 02:13 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
, 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:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:02 AM
MET WITH:Carina DavisTIME COMPLETED:
02:16 PM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to this facility for a required annual inspection. LPA met with facility staff who notified Licensee Carina Davis, who arrived shortly during today's visit. The facility is approved for a Hospice Waiver for six (6) residents.

Physical Plant: The facility is operating within capacity and not beyond the conditions of the license. There are no pools or other bodies of water located on the premises. The facility is being maintained at a comfortable temperature for residents for common areas. All ramps and passageways are kept free of obstruction. Bathrooms have grab bars for each toilet, bathtub and showers used by residents. Fire safety plan includes fire extinguishers purchased on 02/07/2024 and fire alarms. Carbon monoxide detectors are present in the bedroom hallway.

Kitchen and Food Service: LPA was present during lunch time. Food provided to residents appears to be of the quality and in the quantity necessary to meet resident needs. There is at least a two day supply of perishable food items and a seven (7) day supply of non-perishables. The refrigerator and separate freezer are maintained within regulatory temperatures.

Medication, Care, and Supervision: The facility has ensured sufficient and competent staff to provide the services needed to meet resident needs. Chemicals, sharps, and hygiene items are stored inaccessible to residents. LPA reviewed centralized medications list and inspected medications. LPA found medications kept in their original containers and appear to be dispensed according to the physician's orders.

Resident and Staff Files: LPA reviewed a sample of staff and resident files. Staff files had the required documentation including a health screening report and proof of background clearance. Resident files had the required documentation including admission's agreement, appraisal and/or needs and services plan, and updated physician's reports. Current first Aid/CPR certificates are on file. LPA reviewed training for Dementia care and Activities of Daily Living.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: HILLSONG SENIOR LIVING AND HOSPICE
FACILITY NUMBER: 361881032
VISIT DATE: 02/12/2024
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Operations and Administration: Emergency and Disaster Plan is present. Licensee is present in the facility a sufficient amount of hours and their administrator certification is up to date. The required licensing and ombudsman posters are posted. Residents rights are posted and a copy is kept the resident's file.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to Licensee Carina Davis.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
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