365530253-11-17-2025-56-AS-ECOS-DNHSWB-20251117131405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530253
Report Date: 11/17/2025
Date Signed: 11/17/2025 01:14:16 PM

Document Has Been Signed on 11/17/2025 01:14 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:	HILLS OF SOUTH LANE I, THE		FACILITY NUMBER:	365530253
ADMINISTRATOR/ DIRECTOR:	CHAVEZ, REGINA		FACILITY TYPE:	740
ADDRESS:	13045 SOUTH LN		TELEPHONE:	(714) 430-7672
CITY:	REDLANDS	STATE: CA	ZIP CODE:	92373
CAPACITY: 6		CENSUS: 0	DATE:	11/17/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:20 PM
MET WITH:	Regina Chavez, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:20 PM

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Licensing Program Analysts (LPA) Edith Conchas conducted a third announced pre-licensing visit to the facility. LPA met with Facility Administrator Regina Chavez and Chris Cerami. The pending application is for a Residential Care Facility for Elderly (RCFE).

The capacity is six (6). The census is zero. The Administrator accompanied the LPA on a tour of the inside and outside of the facility.

The physical plant, in general, was in good repair. The buildings and grounds are free from hazards. The indoor passageways are free of obstruction. The outdoor passageways were observed to be free of obstruction. LPA observed an in-ground pool at the facility with no water.

All bedrooms are furnished with a bed, night- stand, dresser, and chair. All bedrooms have adequate lighting for resident use. Bathroom's toilet, and showers are in good repair and have non-skid mats. LPA observed two (2) of the communal shower have water stopper to allow the water to drain as intended and keeping it from widespread pooling.

LPA observed both bathroom water temperatures measuring at 105 degrees Fahrenheit.

LPA observed food storage and preparation areas to be clean and sanitary. LPA inspected indoor kitchen a new dual freezer and refrigerator in working condition. There is enough Emergency water supply and the required 72-hour emergency food supply for residents and staffs available at the facility.

The outdoor space is suitable for residents use. LPA observed one (1) fully charged fire extinguisher present in the facility with last inspection of August 13, 2025. Smoke alarms and carbon monoxide are present and functional. Facility has a designated area (Med-cabinet) where medications are locked and stored.

Continue LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: HILLS OF SOUTH LANE I, THE	FACILITY NUMBER: 365530253
	VISIT DATE: 11/17/2025

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The facility had a designated area where staff and resident records are stored. Emergency disaster plans, personal rights, and complaint posters were posted in a common area. There is adequate seating in the common areas. Facility had a supply of activities for the residents. During review of records LPA's found plan of operation, admission agreement, along with an updated facility sketch.

The following are things LPA observed to be completed.

All mattresses have mattress covers/ pads
Back yard surrounding the pool is free of debris.
Back yard pool has a pad lock.
Outdoor fan was replaced with lighting in working condition
Staff files were observed and were complete with updated training, CPR/ First aid and jobs descriptions etc.
Indoor refrigerator was replaced and in working condition.
The indoor magnetic doors (2) are in working condition.

Pre-licensing inspection is complete and meets the requirement to pass the inspection.

Component III was completed on 8/29/2025.

An exit interview was conducted, and a copy of this report was provided to Administrator Regina Chavez Chris Cerami.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Edith Conchas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 11/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

LIC809 (FAS) - (06/04)

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