<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530119
Report Date: 08/22/2025
Date Signed: 08/22/2025 03:01:55 PM

Document Has Been Signed on 08/22/2025 03:01 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITYFACILITY NUMBER:
365530119
ADMINISTRATOR/
DIRECTOR:		TAMMY CHAVEZFACILITY TYPE:
735
ADDRESS:22325 BARTON RD.TELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY: 150CENSUS: 132DATE:
08/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Tammy Chavez, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/22/2025 at 08:40 AM, Licensing Program Analyst (LPA) Eldin Serrano conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA was greeted by Executive Director (ED) Tammy Chavez and gained access to the facility. LPA explained the purpose of the visit to the ED.

The facility has eighty six (86) bedrooms, ninety bathrooms (92) bathrooms, kitchen, dining room, activity room, and courtyard. The facility is licensed for 150 ambulatory of which 30 can be non- ambulatory 1 maybe bedridden. LPA completed a walkthrough of the facility, review of records, Personal and Incidental (P&I) and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD), There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 74 degrees Fahrenheit. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 118 degrees Fahrenheit. The facility is equipped with operational smoke detectors and carbon monoxide detectors, charged fire extinguishers, and first aid kit with first aid book. LPA observed that facility sketch is not posted for both floor. Technical violation issued.

Posters such as the personal rights, CCLD complaint poster, and emergency disaster plan were posted in a common area. Client medications were kept in secure Med-room inaccessible to clients. The facility had emergency water. LPA observed that the facility does not have enough food for 72 hour emergency. Citation issued. There are no firearms and ammunition in the facility.
*** Continuation in LIC809C ***
NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITY
FACILITY NUMBER: 365530119
VISIT DATE: 08/22/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Yards/Outside: One courtyard, two (2) exit gates with self-latching handle on the entrance of the building that leads into the facility and at the back of the facility. Car parking lot observed. All outdoor pathways were free of obstructions.

Food Service: LPA Serrano 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 reviewed five (5) client files for admission agreements, medical assessments/physician reports. LPA observed files reviewed were complete. LPA also reviewed five (5) staff file for First Aid/CPR certification, emergency intervention certification (CPI), criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result and observed files were complete.

LPA audited five (5) clients’ medications. LPA observed that medication log is not properly updated on the actual refill and start date of administration. Deficiency issued. LPA audited five (5) clients’ Personal and Incidental (P&I) and no issues observed.

Deficiencies were cited during this visit per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report LIC809, LIC809C, LIC809D, and LIC9102 and Appeal Rights were discussed, and copies were provided to Executive Director Tammy Chavez.

NAME OF LICENSING PROGRAM MANAGER: Karen Clemons
NAME OF LICENSING PROGRAM ANALYST: Eldin Serrano
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 08/22/2025 03:01 PM - It Cannot Be Edited


Created By: Eldin Serrano On 08/22/2025 at 02:41 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITY
FACILITY NUMBER: 365530119

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(C)
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: (C) A record of each dose is maintained in the client's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the client's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that medication log was correclty updated on the date of medication administration which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
1
2
3
4
 Licensee will submit medication training conducted by a licensed professional signed by all medtech and the training facilitator by the plan of correction (POC) due date.
Type B
Section Cited
HSC
1565(a)(2)
Other Provisions
(a) A facility shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility is equipped with the 72 hour emergency food which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
1
2
3
4
Licensee will submit proof of purchase of the 72 hour emergency food for the facility on the plan of correction (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.
Karen Clemons
NAME OF LICENSING PROGRAM MANAGER:
Eldin Serrano
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5