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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366411345
Report Date: 03/06/2025
Date Signed: 03/06/2025 01:06:39 PM

Document Has Been Signed on 03/06/2025 01:06 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
03/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:40 AM
MET WITH:Kaden Searcy Direct Support ProfessionalTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 3/6/2025 at 10:40 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced case management visit to the facility to follow up on Client 1 (C1)'s death which occurred on 3/04/25. LPA initially met with Direct Support Professional (DSP) Kaden Searcy. The administrator/licensee cannot come to the facility at the time of this report.

LPA spoke with the staff to obtain additional information regarding the death. LPA reviewed C1’s facility file. LPA requested copies of the following documents: Client ID/emergency information, admission's agreement, physician's report, Individual Program Plan (IPP), daily notes, centrally stored medication log, and special incident report/death report.

The Department is requesting a copy of C1's death certificate once it becomes available. Further investigation may be required depending on the cause of death.

No deficiencies were cited during the visit. An exit interview was conducted where this report was discussed and provided to the DSP Kaden Searcy.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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