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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366408868
Report Date: 10/30/2023
Date Signed: 10/30/2023 12:59:48 PM

Document Has Been Signed on 10/30/2023 12:59 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
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: 4DATE:
10/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Kimberly Upchurch, Administrator TIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Javier Prieto made an unannounced case management visit to gather documentation and conduct interviews relating to complaint number 18-AS-20201202151253. LPA stated the purpose of the visit and was granted entry and met with Administrator Kimberly Upchurch. LPA Prieto obtained pertinent documentation and information. LPA Prieto and Administrator Upchurch signed this report and a copy was left with the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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