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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408868
Report Date: 03/24/2022
Date Signed: 03/24/2022 10:00:31 AM

Document Has Been Signed on 03/24/2022 10:00 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
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: 2DATE:
03/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:37 AM
MET WITH:Ronnie UpchurchTIME COMPLETED:
10:04 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on infection control. LPA met with administrator Ronnie Upchurch.

During the inspection, LPA and administrator conducted a brief tour of the facility and made observations pertaining to the facility's infection control measures. LPA observed that the facility had several COVID-19 related postings throughout the facility. The facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and a 30+ day supply of Personal Protective Equipment (PPE). LPA observed all staff members were properly fitted with face coverings.

This facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining clients, and properly caring for clients with COVID-19 positive results and/or exposures. The facility also has a plan in place to monitor clients regularly for any changes in condition and to subsequently notify the responsible parties and medical personnel in the event the client presents with any COVID-19 symptoms.

LPA Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where a copy of this report was discussed and provided to Mr. Upchurch at the conclusion of the inspection.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2022
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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