365530119-12-19-2025-56-AS-KCLS-DPV6Q5-20251230200009

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 365530119
Report Date: 12/19/2025
Date Signed: 12/19/2025 01:26:14 PM

Unsubstantiated

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
12/15/2025 and conducted by Evaluator Eldin Serrano

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20251215095606

FACILITY NAME:	JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITY		FACILITY NUMBER:	365530119
ADMINISTRATOR:	TAMMY CHAVEZ		FACILITY TYPE:	735
ADDRESS:	22325 BARTON RD.		TELEPHONE:	(909) 420-0153
CITY:	GRAND TERRACE	STATE: CA	ZIP CODE:	92313
CAPACITY:	150	CENSUS: 130	DATE:	12/19/2025
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Tammy Chavez,Executive Director		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff does not prevent the facility from being mal odorous
Staff do not prevent residents from smoking inside the facility

INVESTIGATION FINDINGS:

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On 12/19/2025 at 9:50 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to investigate and deliver the findings of the above allegations. LPA Serrano met with Executive Director Tammy Chavez to explain the purpose of the visit. The investigation consisted of file review, interviews with facility staff and clients as well as facility observation.

Allegation #1: Staff does not prevent the facility from being mal odorous – Based on information received during staff and client’s interviews, all of them stated that the clients have a designated smoking area located in the courtyard of the facility. Staff stated that they tried to keep all the doors and windows closed so the smell of cigarette smoke does not come inside the building. If there is a smoke smell that went through the door crack the housekeeping use aerosol spray to eliminate the smell. LPA observed staff vacuuming and cleaning the resident rooms and in hallways and common area. Facility also provided the housekeeping schedule. LPA was unable to corroborate the allegation.
*** Continuation in LIC9099C ***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20251215095606

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: 12/19/2025

NARRATIVE

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Allegation #2: Staff do not prevent residents from smoking inside the facility - Based on interviews with clients and staff, all of them stated that smoking is not allowed inside the building. The security and staff do a safety check in the client’s room to make sure no one is violating the facility policy. Facility provided the non- smoking policy attached to the client’s admission agreement. If the resident is caught smoking or have in their room or in possession of any prohibited items (lighter, cigarettes, drugs, incendiary items), it will be immediately confiscated. LPA was unable to corroborate the allegation

Information received during investigation LPA did not find evidence to corroborate the allegations.

Based on the evidence, the allegations mentioned above are UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted where this report, LIC9099 was discussed and provided to Executive Director Tammy Chavez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2025

LIC9099 (FAS) - (06/04)

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