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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366426334
Report Date: 10/28/2025
Date Signed: 10/28/2025 03:23:22 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/09/2025 and conducted by Evaluator Beena Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20251009140110
FACILITY NAME:UPCHURCH ARF-PINE VALLEYFACILITY NUMBER:
366426334
ADMINISTRATOR:KIMBERLY UPCHURCHFACILITY TYPE:
735
ADDRESS:5855 PINE VALLEY DR.TELEPHONE:
(909) 371-3457
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:5CENSUS: 2DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Staff/Caregiver Megan UpchurchTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff struck a resident in the head.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Beena Singh arrived at the facility to deliver findings on an open complaint with the above allegation. LPA Singh identified herself and discussed the purpose of the visit and the elements of the above allegation with Staff/Caregiver Megan Upchurch.

Below is a summary of the findings:

Regarding the allegation "Staff struck a resident in the head": LPA Singh conducted investigation, collected pertinent documents, interviewed relevant parties, outside agencies, family and staff in question regarding the allegation" Staff struck a resident in the head" has been unsubtantiated due to lack of evidence. Three(3) out of three(3) facility staff and two (2) out of two (2) clients at the facility denied the allegation that staff struck a resident in the head and two(2) out of two(2) clients stated Staff has never hit or struck the clients in care ever.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 56-AS-20251009140110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 ARF-PINE VALLEY
FACILITY NUMBER: 366426334
VISIT DATE: 10/28/2025
NARRATIVE
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Based on the evidence found during the investigation, the allegations listed above is deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted and discussed this report and a copy of this report LIC9099 was provided to Staff/Caregiver Megan Upchurch

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Beena Singh
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2