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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366408868
Report Date: 11/26/2024
Date Signed: 11/26/2024 02:22:24 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/02/2020 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201202151253
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: 3DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maxine Brown, CaregiverTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Neglect/lack of care and supervision resulted in Client #1 (C1) sustaining multiple injuries.
INVESTIGATION FINDINGS:
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On December 2, 2020, the Department received a complaint with allegation of personal rights violation resulting in C1 sustaining injuries. The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals.

Investigation revealed that on November 6, 2020, around 7:00 am, S1 observed that C1 feet appeared swollen. Interviews revealed that shortly before lunch on same day, C1 was incontinent and was provided a bath. According to S1, after the bath, C1 feet appeared red. S1 reported that later, C1 was observed to be peeling off the skin on the top of C1 feet. S1 reported that C1 feet were extremely red but there was no blisters or blood. Treatment was applied to C1 feet, according to S1. Around 12:30 pm, S2 was notified of what was occurring with C1. S2 reported that C1 primary physician was contacted and C1 was sent to local hospital. According to S2, she was not at facility at this time on November 6, 2020. S2 reported that she was sent a picture of C1 feet and S2 forwarded the picture to C1 primary physician. Following physician contact, emergency services were called for C1.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 3
Control Number 18-AS-20201202151253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: UPCHURCH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366408868
VISIT DATE: 11/26/2024
NARRATIVE
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Around 2:20 pm on November 6, 2020, C1 was admitted to the local hospital. Per medical records, C1 was admitted with “bilateral 2nd degree superficial vs deep noted to feet up to the mid tibia with linear demarcation to normal skin. Blister lesion noted on the plantar aspect of the right foot… Patient has redness to left arm and below elbow, blistering, redness, swelling, and skin peeled to bilateral lower extremities below knee.”

Around 10:00 pm on November 6, 2020, C1 was transferred from the local hospital to a regional hospital. Per investigation, the reason for transfer was indicated as C1 need for higher level of care. According to medical records from this regional hospital, C1 had “2nd degree burn of groin, 2nd degree burn of left ankle, left foot, right ankle, right foot. 1st degree burn of back, burn of arm, burn of buttock. Bilaterally lower extremity circumferential burns. 1st degree burn circumferential from mid forearm to through hand on the left extra upper extremity, first degree burns from mid back down to mid-thigh bilaterally, 2nd degree blistering burns on the inner thighs bilaterally. Non blanching circumferential 2nd degree burns to bilateral feet and calves. Bruises in multiple stages of healing. Medical records further indicate “distribution suggestive of burns with hot water in bathtub or shower.”

According to facility records, C1 requires total assistance with bathing. As found during investigation, C1 was bathed by facility staff prior to observation of swelling and redness to C1 feet. Facility records reviewed also indicate that C1 needs assistance with activities of daily living including incontinent care, dressing, and hygiene care.
Based upon investigation, the preponderance of the evidence supports that staff neglect/lack of care and supervision resulted in C1 sustaining multiple injuries. On or November 6, 2020, C1 was residing at the facility and sustained burns to various areas of C1 body. C1 was sent to two different hospitals, with both hospitals identifying that C1 had multiple injuries including 1st and 2nd degree burns. During the investigation, staff could not recall when a burn may have occurred to C1 nor recall observation of the other multiple injuries that was found upon hospitalization. As a result of staff neglect with failure to ensure required care, supervision, and safe accommodations, C1 sustained multiple injuries. Allegation is substantiated.

The following deficiency is cited per California Code of Regulations, Title, 22. In addition, an Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that additional civil penalty may be assessed based on Health and Safety Code 1548 (f) (1) (A).
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20201202151253
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: UPCHURCH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366408868
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2024
Section Cited
CCR
80072
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80072 Personal Rights
(a)(2) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following... to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
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The licensee shall conduct in-service training to all staff in regard to the residents’ personal rights. Proof will be submitted to the Department by 12/10/2024
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The requirement was not met as evidenced by: Based on interviews, records review, and observations, licensee did not ensure C1 was accorded safe, healthful, and comfortable accommodations. C1 sustained multiple injuries, including 1st and 2nd degrees burns to various areas of C1 body. This poses an immediate health and safety risk to residents 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: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
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