Hillsong Senior Living

Type of visit: Required - 1 Year

On 4/24/2026 Licensing Program Analyst (LPA) LaVette Farlow arrived unannounced to conduct the required comprehensive annual inspection to the facility. LPA was greeted and granted access into the facility by Administrator, Carina Davis and introduced self and stated purpose of the visit. During the visit LPA was escorted by Carina on a tour and the following information was observed: The facility has 5 bedrooms, 1 of the 5 rooms is for staff, 3 bathrooms, kitchen, dining area, family room, living room, lock laundry area, attached garage, and backyard. LPA completed a walk through of facility, review of records, and conducted a random audit of the medication. Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean and appliances were found functional. LPA observed that facility has a sufficient supply of hygiene items for residents in care. Water temperatures tested at 113.5, 111.0, and 109.5 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms and charged fire extinguisher. LPA observed poster on display for personal rights, and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept in secure cabinets, inaccessible to residents. There was a designated storage space for client/staff files. Medications and first aid kit were in secure cabinets and inaccessible to residents. There are no firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions. Food Service: LPA observed that the facility has a sufficient supply of perishable and non-perishable items. The facility has sufficient supply of dishes, cups, and utensils were also stored properly. Emergency food and water were observed. Yards/Outside: LPA observed one shaded patio, a side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. LPA observed a garden with fresh fruit and vegetables in the backyard. Record Review: LPA reviewed Administrator and 3 staff files for First Aid/CPR certification, criminal record clearance, training, health screenings and TB test. LPA observed that 3 staff were missing a health screening, but everyone had TB test results available. A Technical Violation issue. LPA reviewed 3 residents files for admissions agreements, pre-admissions appraisals, physician's reports, needs and service plans. Personnel records and residents file appeared to be complete and in order. LPA observed 3 out of 3 resident were missing a needs and service plan. A Technical Violation issued. LPA conducted an audit of the resident MARs and Centrally Stored Medication log. LPA observed that 1 out of 3 residents had one medication missing from the residents MARs. A Deficiency Cited. One (1) deficiency and two (2) Technical Violation issued during this visit per Title 22, chapter 6 California Code of Regulation. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV and Appeals Rights were discussed and copies were provided to Administrator, Carina Davis.the state’s words, verbatim · CDSS document, Apr 24, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Prelicensing

On 4/7/2025 at 09:30 AM, Licensing Program Analysts (LPA) Eldin Serrano conducted an announced visit to the facility for purpose of Prelicensing evaluation. LPA met with Applicant Carina Davis. An initial application to operate a Residential Care for the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 10/15/2024 for a total capacity of six (6) nonambulatory, of which two (2) maybe bedridden and waiver/granted for hospice care for six (6). Fire clearance was granted on 2/5/2025 for six (6) non-ambulatory residents and two (2) bedridden. LPA Serrano observed the following: Structure: Facility was a one (1) story house with five (5) resident bedrooms, and two and half (2.5) bathrooms, living room, dining area/kitchen and laundry. There was an attached two (2) car garage in the left side of the house. Heating/Cooling System: Central heating and air conditioning system installed with one (1) central panel located in the hallway to control entire house. Bedrooms: Each resident bedrooms accommodate any nonambulatory residents and bedroom #2,#3,#4 is for bedridden resident. All resident bedrooms were adequately furnished with bed, chair, closet, appropriate linens, adequate lighting, nightstands, a lamp and an operable smoke/carbon monoxide alarm. ***CONTINUED ON LIC 809-C*** Bathrooms: The two and half (2) resident/staff bathrooms have a working toilet, wash basin, grab bars, non-slip mat and shower with an adequate supply of toilet paper and soap. LPA Serrano tested the water temperatures in the residents' bathrooms. LPA Serrano verified water temperature was measured at 111.9 degrees Fahrenheit. Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives/sharp instruments were secured in a locked closet in the hallway. There was adequate room for food storage. LPA Serrano observed the stove to be operational. Refrigerator/freezer were in working condition. There is sufficient storage for perishable food. There was adequate seating for meals for all clients. Laundry room with washer and dryer was in the laundry room. Laundry detergents and cleaning supplies were observed in a locked cabinet. Garage door is locked away from residents. Living Room: There was a living/family room with adequate seating for all clients and a working TV. Linens and Hygiene Supplies: An adequate supply of linens was stored in a cabinet in the hallway of the residence. Yards/Outside: Patio furniture for outdoor seating observed. Self-latching handle gate on left side of the house that leads into the backyard. All outdoor pathways were free of obstructions. Emergency Phone Numbers, and Exit Plan: Facility sketch was observed posted near the main entrance. Emergency/Disaster plan posted by the entrance. There was Let-Us-Know poster. . Dementia Care Plan: LPA Serrano observed and reviewed the Dementia Care Plan during the visit. ***CONTINUED ON LIC 809-C*** General items: Two (2) fire extinguishers were charged and located in the hallway and kitchen. Seven (7) combined smoke detectors and carbon monoxide detectors were tested and were observed to be in working order. Resident records and staff records will be stored in a locked cabinet in the hallway. First Aid kit with required components, First Aid Book and locked area for medication storage was observed. LPA observed a facility phone and was operational as evidenced by LPA dialing the number. The phone number designated for the facility is 909-570-9139. There is enough Emergency water supply and the required 72-hour emergency food supply for residents and staffs available at the facility. Component III was completed on this day as well. Additionally, LPA Serrano observed facility having Visitor Sign In/Sign Out Sheet and Client Sign In/Sign Out Sheet, upon entering facility. The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22, Division 6, Chapters 1 and 6 to ensure the health and safety of clients in care. Facility appears to be ready for licensure. An exit interview was conducted, and a copy of this report, LIC809 was discussed and provided to Applicant Carina Davis.the state’s words, verbatim · CDSS document, Apr 7, 2025

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: DAVIS, CARINA - Licensee/Administrator Interview Method: Telephone interview On 03/18/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Mar 18, 2025