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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366408868
Report Date: 09/20/2023
Date Signed: 09/20/2023 10:17:24 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2021 and conducted by Evaluator Tricia Danielson
COMPLAINT CONTROL NUMBER: 18-AS-20210806131118
FACILITY NAME:UPCHURCH ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
366408868
ADMINISTRATOR:KIMBERLY UPCHURCHFACILITY TYPE:
735
ADDRESS:4253 DENVER STREETTELEPHONE:
(909) 624-3485
CITY:MONTCLAIRSTATE: CAZIP CODE:
91763
CAPACITY:6CENSUS: 4DATE:
09/20/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Tess Glasscock, CaregiverTIME COMPLETED:
10:20 AM
ALLEGATION(S):
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Licensee delayed obtaining adequate medical attention
Licensee failed to administer prescribed medication as ordered
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conclude an investigation into the allegations listed above. LPA was greeted and granted entry by Caregiver Tess Glasscock. LPA met with Licensee/Administrator Kimberly Upchurch via telephone and explained the purpose of today's visit. Regarding the allegation “Licensee delayed obtaining adequate medical attention”, it was alleged that Client #1 (C1) was not adequately evaluated for medical treatment after repeatedly falling on their already broken arm. Review of Special Incident Report dated 6/22/21, indicated C1 had been taken to the hospital on 6/21/21, after falling from a chair on purpose for attention. C1 was diagnosed with a fractured arm. Upon return to the facility on 6/22/21, C1 fell on the arm on purpose again at least twice. A medical re-evaluation was not sought until 6/24/21, and only after the swelling and bruising to C1’s arm had increased. Regarding the allegation “Licensee failed to administer prescribed medication as ordered”, it was alleged that C1 had not been given prescribed pain medication in June 2021 and antibiotics had not been given in full as prescribed in May and June 2021 based on a lack of initialed Medication Administration Records (MARs). Review of C1's MARs for the months of May and June 2021 revealed C1 each dosage of antibiotic was initialed as given. (CONTINUED ON LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 18-AS-20210806131118
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: UPCHURCH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366408868
VISIT DATE: 09/20/2023
NARRATIVE
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(CONTINUED FROM LIC9099)
Review of the facility’s Centrally Stored Medication and Destruction Records for June 2021 revealed C1’s prescription for Medication#1 (M1) was filled 6/30/21. However, review of Special Incident Report dated 6/25/21, documented by Licensee Upchurch, indicated C1 had been discharged from the hospital on 6/24/21 with a prescription for pain medication. Therefore, the prescription was not filled until six (6) days later. The MARs also indicated only one dosage of M1 was signed as given on July 1, 2021.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations (Title 22, Division 6, Chapter 8), are cited on the attached LIC 9099-D.
An exit interview was conducted, and a copy of this report was provided along with Appeal Rights and LIC811- Confidential Names list.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20210806131118
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: UPCHURCH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366408868
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2023
Section Cited
CCR
80075(a)
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Health Related Services- (a)The licensee shall ensure that each client receives necessary first aid and other needed medical or dental services, including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidenced by:
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The licensee will submit a written statement of understanding of the regulation cited and retrain all staff of the client's right to be offered medical attention. Proof of POC to be submitted to CCL by 9/29/23 at 5PM.
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The licensee did not ensure C1 received necessary medical services. Based on records reviewed, on 6/22/21, C1 fell on their already broken arm at least twice but was not medically re-evaluated until 6/24/21. This poses a potential health, safety, and personal rights risk to clients in care.
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Type B
09/29/2023
Section Cited
CCR
80075(b)
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Health Related Services- (b)Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidenced by: The licensee did not ensure C1 received assistance as needed with
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The licensee will submit a written statement of understanding of the regulation cited and retrain all staff of the importance of obtaining prescribed meds without delay. Proof of POC to be submitted to CCL by 9/29/23 at 5PM.
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self-administration of prescription medications. Based on records reviewed, C1's 6/24/201 M1 was not filled until 6/30/21. This poses a potential health, safety, and personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Tricia Danielson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7