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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426334
Report Date: 02/12/2024
Date Signed: 02/12/2024 12:16:37 PM


Document Has Been Signed on 02/12/2024 12:16 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 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: 4DATE:
02/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Staff Marty AguayoTIME COMPLETED:
12:20 PM
NARRATIVE
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On 02/12/2024 at 09:04 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA Brown knocked on the door and pressed the door bell. LPA walked around the home and did not observe any persons inside the home. At 09:10 AM, LPA Brown contacted facility phone number, no answer, then contacted Licensee/Administrator Kimberly Upchurch and Licensee/Administrator Upchurch reported that staff transported the clients to their Day Program and indicated that Licensee/Administrator Upchurch will be arriving in the facility in an hour. Licensee/Administrator Upchurch added that staff will be contacted that LPA Brown's waiting at the facility. LPA Brown received a text message from Licensee/Administrator Upchurch that staff was contacted and informed that LPA Brown's at the home, also Licensee/Administrator Upchurch confirmed to LPA Brown that they will be arriving soon. Staff #2 (S2) arrived at the facility at 09:56 AM. LPA Brown explained the purpose of today's visit to S2.

The facility has 4 bedrooms, 3 bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA Brown completed a walkthrough of the facility, review of records, and medications audit.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL), LPA Brown observed no client during the visit. S2 reported to LPA Brown that all clients are out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA Brown inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA Brown inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 106 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, charged fire extinguisher, and first aid kit with first aid book.
*** Continuation in LIC809C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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 ARF-PINE VALLEY
FACILITY NUMBER: 366426334
VISIT DATE: 02/12/2024
NARRATIVE
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Posters such as; the personal rights, CCL complaint poster, emergency disaster plan were posted in a common area. Sharps and client medications were kept in secure cabinets inaccessible to clients. Moreover, LPA Brown observed no night lights maintained in hallways and passages to nonprivate bathrooms at the facility. Deficiency will be issued. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility. Overall, the facility is clean, and operates in safe conditions for clients in care.

Yards/Outside: One shaded patio, one (1) side gate with self-latching handle on the left side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.



Record Review: LPA Brown reviewed client files for admission agreements, medical assessments/physician reports and Inland Regional Center (IRC) Individual Program Plan (IPP). LPA Brown observed that client files are complete. LPA also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis test result. LPA Brown observed that Staff #3 (S3) does not have the required Tuberculosis (TB) Test result maintained in S3 facility file and not reflected on S3's Health Screening Report. Deficiency will be issued.

LPA Brown audited two (2) clients medications and LPA Brown observed one of Client #4 (C4) medication was dispensed but C4's Medication Administration Record (MAR) was not updated per physician order. Deficiency will be issued. Two (2) clients P&I were audited, no issues were observed.

Deficiencies were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and Appeal Rights were discussed and copies were provided to Staff Marty Aguayo .

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/12/2024 12:16 PM - It Cannot Be Edited

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 ARF-PINE VALLEY
FACILITY NUMBER: 366426334

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio, interview and record revie], the licensee did not comply with the section cited above by dispensing one (1) medication of Client #4 (C4) and not updating C4's Medication Administration Record (MAR) per physiician which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/13/2024
Plan of Correction
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Licensee stated to train all staff on CCR 80075(b)(5)(B) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 02/12/2024 12:16 PM - It Cannot Be Edited

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 ARF-PINE VALLEY
FACILITY NUMBER: 366426334

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(e)(2)
Fixtures, Furniture, Equipment, and Supplies
(e) Emergency lighting, which shall include at a minimum working flashlights or other battery-powered lighting, shall be maintained and readily available in areas accessible to clients and staff. (2) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio, interview and record review, the licensee did not comply with the section cited above by not having night light maintained in hallways and passages to non-private bathrooms at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee stated to obtain or purchased the required night lights to be maintained in hallways and passages to common bathrooms and submit proof to LPA Brown at Plan of Correction (POC) due date.
Type B
Section Cited
CCR
80066(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) Tuberculosis test documents as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review the licensee did not comply with the section cited above by not having Staff #3 (S3) Tuberculosis Test Resultt mainatined in S3 facility file and not reflected in S3 Health Screening report which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2024
Plan of Correction
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Licensee stated to provide LPA Brown of S3's Tuberculosis (TB) Test Result and updated Health Screening Report at POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 02/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/12/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4