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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530119
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:50:11 PM

Document Has Been Signed on 07/06/2023 03:50 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:JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITYFACILITY NUMBER:
365530119
ADMINISTRATOR:WITTLETT, ASHLEYFACILITY TYPE:
735
ADDRESS:22325 BARTON RD.TELEPHONE:
(415) 710-7538
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY: 150CENSUS: 0DATE:
07/06/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator Ashley WittlettsTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted an announced visit for purpose of a pre licensing visit. An application was submitted for an Adult Residential Facility to the Central Applications Unit (CAU) on 04/03/2023. Fire Clearance was granted 04/20/2023 for a capacity of 119 ambulatory, 30 non-ambulatory and 1 bedridden resident. LPA Goldenberg observed the following:

Structure: Facility was a two story building with 87 bedrooms.

Heating/Cooling System: Central heating and air conditioning systems.

Bedrooms: All bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting.

Bathrooms: Bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, toilet paper, and toiletries. Water temperature measured and read by LPA at 112 F.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were inaccessible. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. There was adequate seating for meals.

Living/Family room: Furnished with safe and adequate seating and furnishings. All items appear to be in good repair.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2023
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: JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITY
FACILITY NUMBER: 365530119
VISIT DATE: 07/06/2023
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Linens and Hygiene Supplies: An adequate supply of linens was available.

Yards/Outside: The facility has a central courtyard for outdoor use, complete with a patio, adequate covered area for providing shade. There were no obstructions observed preventing resident access. There were no bodies of water observed anywhere on the property.

Emergency Phone Numbers, and Exit Plan: Let-Us-No poster and clients rights are posted.

General items: The facility has smoke/carbon monoxide detectors in each living unit. A test was conducted to show how they operated. Each unit has a call system and Administrator showed LPA how the system will function when in use. LPA observed a facility phone and it was verified to be operational by LPA.

LPA reviewed COMPONENT III with Ashley Willett during this Pre Licensing Inspection.

Based on LPA findings during this inspection, this facility physical plant is prepared for licensure at this time.

A copy of this report was reviewed with and a copy was provided to Ashley Willett, Administrator.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2023
LIC809 (FAS) - (06/04)
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