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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408868
Report Date: 05/16/2023
Date Signed: 05/16/2023 02:20:24 PM

Document Has Been Signed on 05/16/2023 02:20 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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: 1DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Tess, Staff MemberTIME COMPLETED:
02:20 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Upchurch Adult Residential Facility unannounced to conduct an Annual Inspection. LPA was greeted by staff member, Tess and granted entry. LPA introduced self and stated purpose of the visit. LPA informed the current census is 1. There are five (5) residents in care at this time; the remaining 4 residents are attending their prospective Day Programs.

Today's visit consisted of a tour of the facility, staff and resident file reviews and staff interviews.
The facility consists of 5 bedrooms, 1 staff room, 3 bathrooms, 1 living room, a kitchen/dining room, and a garage. This facility is also vendorized by the Inland Regional Center.

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 was maintained at 75 degrees during visit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were operating appropriately. LPA tested the temperature from the kitchen faucet, which ranged between 95 degrees and 108 degrees F. The facility is equipped with operable smoke detectors and carbon monoxide detectors; which were tested during visit. Posters such as; the personal rights and disaster plans were posted in a common area. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to clients; in a cabinet next to the kitchen. There was a designated storage space for client/staff files in a secure file cabinet in the facility's office area. Medications were kept secure in a file cabinet near the kitchen and inaccessible to residents. The facility had emergency and first aid kits readily available for residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: UPCHURCH ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 366408868
VISIT DATE: 05/16/2023
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Food Service: Non-perishable and perishable food supply is sufficient for number of clients residing in the facility. Facility offers a variety of food available for residents. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.
Record Review: LPA reviewed 2 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. The facility's Medication Administrative Record was reviewed and was consistent with the resident's medications lists.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A Technical Violation was issued due to gates on side gates being locked at the time of visit. Staff completed correction during visit. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC809 (FAS) - (06/04)
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