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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411345
Report Date: 08/19/2022
Date Signed: 08/19/2022 03:48:47 PM

Document Has Been Signed on 08/19/2022 03:48 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 #2FACILITY NUMBER:
366411345
ADMINISTRATOR:KIMBERLY UPCHURCHFACILITY TYPE:
735
ADDRESS:11970 WALNUTTELEPHONE:
(909) 258-3199
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 4CENSUS: 3DATE:
08/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:48 PM
MET WITH:Administrator Kimberly UpchurchTIME COMPLETED:
03:55 PM
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Licensing Program Analyst Bernadette Allen conducted an unannounced required 1 year visit. LPA was granted entrance and met with administrator Kimberly Upchurch..

LPA observed prior to the visit to the facility that they have a mitigation plan to mitigate the spread of COVID-19 in the facility. One central entry point and sign-in policy has been designated for universal entry screening. Routine symptom screening has been initiated at entry for all staff, clients, and visitors. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and clients.

LPA toured the facility inside and out and there were no health and safety concerns. The facility has charged fire extinguishers, operating smoke alarms, and carbon monoxide detectors. The outdoor and indoor hallways were also free of obstruction. Cleaning supplies are locked in garage.

The facility had a complete first aid kit and emergency supplies for LPA observed a two (2) day supply of perishable food items and seven (7) day supply of nonperishable food items. The facility menu was available for review.

The client rooms had the required furniture and sufficient lighting. The bathrooms can accommodate the needs for bathing and showers have non-slip flooring. The facility had a supply of additional linen and extra hygiene items for the clients. LPA measured the hot water temperature in the main upstairs bathroom. The hot water temperature measured at 107.4 degrees F.

LPA observed hand sanitizer throughout the facility and a 30- day supply of PPE.

No cited deficiencies per Title 22, Division 6 of the California Code of Regulations cited at this time.


Exit interview conducted and copy of report provided to Kimberly Upchurch
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2022
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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