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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530119
Report Date: 08/09/2023
Date Signed: 08/09/2023 12:52:26 PM

Document Has Been Signed on 08/09/2023 12:52 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:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY: 150CENSUS: 9DATE:
08/09/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ashley Willett, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Amy Goldenberg and Bernadette Allen made an unannounced post licensing visit this date. The inspection consisted of but was not limited to the following: Infection Control, physical plant and environmental safety, operational requirements, staffing, personnel records, clients rights, clients records, food service, health related services, and incidental medical and dental.

Based on today's inspection, per Title 22, Division 6 of the California Code of Regulations there were no deficiencies observed during visit.

This report was reviewed with and a copy was provided to the facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amy Goldenberg
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2023
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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