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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881032
Report Date: 01/24/2025
Date Signed: 01/24/2025 01:27:44 PM

Document Has Been Signed on 01/24/2025 01:27 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HILLSONG SENIOR LIVING AND HOSPICEFACILITY NUMBER:
361881032
ADMINISTRATOR/
DIRECTOR:		DAVIS, CARINA K.FACILITY TYPE:
740
ADDRESS:2434 CIENEGA DR.TELEPHONE:
(909) 232-9834
CITY:HIGHLANDSTATE: CAZIP CODE:
92346
CAPACITY: 6CENSUS: 6DATE:
01/24/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:11 AM
MET WITH:Carina DavisTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 01/24/2025 at 9:11AM, Licensing Program Analyst (LPA) Renese Howell-Small arrived unannounced to conduct the required annual visit to the facility. LPA met with Licensee, Carina Davis and introduced self and stated the purpose of the visit. LPA was informed that there are currently 6 residents in care. The facility is approved for a Hospice Waiver for 6.

The facility has 4 bedrooms, 3 bathrooms, kitchen, dining area, living room, office, laundry, attached two car garage and backyard. LPA completed a walk through of the facility, review of records and medication audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. Water temperatures tested at 124 degrees Fahrenheit. The facility is equipped with operational smoke detectors, a carbon monoxide alarm, charged fire extinguishers and first aid kit with book.

Posters such as; the personal rights, emergency disaster plan, CCLD complaint poster and ombudsman were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible to residents. There was a designated storage space for resident/staff files. Medications were observed to be locked and inaccessible to residents. There are no bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: HILLSONG SENIOR LIVING AND HOSPICE
FACILITY NUMBER: 361881032
VISIT DATE: 01/24/2025
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Food Service: Non-perishable and perishable food supply is sufficient for residents in care. Dishes, cups, and utensils were also stored properly.

Yards/Outside: One shaded patio, side gate with self-latching handle on the left side of the house that leads into the backyard.



Record Review: LPA reviewed staff and administrator files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA reviewed resident files for admission agreements, updated physician reports, and needs and services plans.

No deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, and LIC809C were discussed and copies were provided to Licensee, Carina Davis.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2025
LIC809 (FAS) - (06/04)
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