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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530119
Report Date: 09/24/2024
Date Signed: 09/24/2024 03:59:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2024 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240919151957
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: 97DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Jessica Langston, Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff refused to accept client at the facility after being discharged from the hospital.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/24/2024 at 9:25 AM Licensing Program Analysts (LPA) Melody Brown and Eldin Serrano arrived at the facility to investigate a complaint and deliver the findings for the above complaint allegation. Upon arrival, LPAs Brown and Serrano met with Executive Director (ED) Jessica Langston, and LPA's Brown and Serrano informed ED Langston of the purpose of the visit.

The investigation consisted of file review and interviews with relevant parties. LPAs Brown and Serrano conducted interviews with relevant parties, and reviewed facility files. The allegation indicates Staff refused to accept client at the facility after being discharged from the hospital. During the investigation, LPAs Brown and Serrano obtained evidence to corroborate the allegation. ED Langston reported that they were informed by Client #1 (C1) Conservator that the bed for C1 will be closed during their Case Management Meeting conducted on 09/17/2024.
*** Continuation in LIC9099C ***

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20240919151957
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/24/2024
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
 In addition, ED Langston indicated that they received an information via email from Department of Behavioral Health (DBH) that the bed for C1’s closed effective 09/17/2024. However, C1’s Conservator informed LPAs Brown and Serrano that they decided to close C1’s bed at the facility because during their Case Management Meeting on 09/17/2024, Facility Representative 1 specifically told them at the meeting that “If C1 cannot ambulate, then C1 cannot be here.” Furthermore, C1’s Conservator indicated that they decided to close C1’s bed at the facility because the staffs at the facility did not provide information to them that they can accept clients that are non-ambulatory. Due to facility staffs did not provide the information that they can accept non-ambulatoty clients, they believed that the facility cannot meet C1's needs. C1’s Conservator emphasized that they were concern for C1’s safety that’s why they decided to close C1’s bed at the facility because they did not know that the facility can accept non-ambulatory clients. C1’s Conservator added that if they were informed that the facility can accept non-ambulatory clients, they will not close C1’s bed at the facility. Per interview, LPAs Brown and Serrano noted that facility staffs did not inform C1’s Conservator that they can accept non-ambulatory clients, which leads to C1’s Conservator and DBH closing C1’s bed at the facility. LPAs noted that the facility’s licensed for 150 ambulatory and 30 may be non-ambulatory clients and one (1) may be bedridden which leads to C1’s Conservator and DBH closing C1’s bed at the facility. Because the facility did not inform C1’s Conservator and DBH that they can accept non-ambulatory clients that resulted to C1’s Conservator and DBH closing C1’s bed for C1’s safety, the facility did not accept C1 back after being discharged from the hospital on 09/18/2024 and no 30 Days Eviction Notice was also issued to C1's Conservator. LPAs Brown and Serrano will be issuing a citation.

Based on LPAs Brown and Serrano observations and interviews and records review conducted, the preponderance of evidence standard has been met, therefore, the allegation of Staff refused to accept client at the facility after being discharged from the hospital is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 6 is being cited on the attached LIC9099D.

An exit interview was conducted where this report LIC9099, LIC9099D, and Appeal Rights were discussed and provided to Executive Director Jessica Langston.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240919151957
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
09/27/2024
Section Cited
CCR
80068.5(a)(4)
1
2
3
4
5
6
7
80068.5 Eviction Procedures (a) Except for children's residential facilities, the licensee may, upon 30 days written notice to the client, evict the client only for one or more of the following reasons: (4) Inability to meet the client's needs.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to accept back C1 to the facility from the hospital and submit proof to LPA Eldin Serrano on Plan of Correction (POC) due date.
8
9
10
11
12
13
14
Based on observation, interview and records review, the Licensee did not comply with the section cited above by not informing C1’s Conservator and Department of Behavioral Health (DBH) that they can accept non-ambulatory clients that resulted to C1’s Conservator and DBH closing C1’s bed for C1’s safety and the facility not accepting C1 back after being discharged from the hospital and no 30 days Eviction Notice was also issued which poses a potential health, safety and personal rights risks to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3