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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411345
Report Date: 09/26/2024
Date Signed: 09/26/2024 01:21:13 PM

Document Has Been Signed on 09/26/2024 01:21 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/
DIRECTOR:		KIMBERLY UPCHURCHFACILITY TYPE:
735
ADDRESS:11970 WALNUTTELEPHONE:
(909) 258-3199
CITY:BLOOMINGTONSTATE: CAZIP CODE:
92316
CAPACITY: 4CENSUS: 4DATE:
09/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:25 PM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced required annual visit. LPA was granted entrance and met with Kimberly Upchruch- Licensee.

The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. All clients were at day program during the visit.

LPA inspected clients bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately.

LPA observed charged fire extinguishers, fire alarm system and carbon monoxide units are operable, hazardous items are kept inaccessible to residents. Hot water was tested reading 105- 120 degrees F.

Kitchen/Food Service: observed entire kitchen, food is stored properly and dishes are clean. There is a sufficient supply of perishable and non-perishable foods for the clients in care.

Care & Supervision: Facility has sufficient care staff.

Administration: Emergency exiting plans, telephone numbers and Ombudsman information are posted.

Record Review: LPA reviewed two (2) client files for admission agreements, updated physician reports, and needs and services plans the clients in care doesn't have any PNI funds.

LPA also reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training's, and health screenings.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: UPCHURCH ADULT RESIDENTIAL #2
FACILITY NUMBER: 366411345
VISIT DATE: 09/26/2024
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Medication: Medications were audited at random and appeared to be dispensed appropriately by staff members.

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

Exit interview was discussed and provided to Kimberly Upchurch at the conclusion of the visit with appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
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