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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530119
Report Date: 10/18/2023
Date Signed: 10/18/2023 11:23:03 AM

Document Has Been Signed on 10/18/2023 11:23 AM - 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:BRITTANY KAVANAUGHFACILITY TYPE:
735
ADDRESS:22325 BARTON RD.TELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY: 150CENSUS: 44DATE:
10/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Olevia Labeeb and Brittany Kavanaugh, Executive StaffTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Amy Goldenberg conducted this unannounced case management for the purpose of conducting resident interviews in regard to complaint control number 56-AS-20230927094455. During this visit LPA interviewed ten (10) residents.

Based on the information obtained during this case management visit, there are no deficiencies being cited per Title 22, Division 6 of The California Code of Regulations. 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: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2023
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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