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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530119
Report Date: 04/08/2026
Date Signed: 04/08/2026 10:41:58 AM

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
04/01/2026 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260401114051
FACILITY NAME:JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITYFACILITY NUMBER:
365530119
ADMINISTRATOR:TAMMY CHAVEZFACILITY TYPE:
735
ADDRESS:22325 BARTON RD.TELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:150CENSUS: 132DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tammy Chavez, Executive DirectorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has mold in clients bathroom
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On April 8, 2026 at 10:00 AM, Licensing Program Analysts (LPA) Eldin Serrano visited the facility to investigate the above-mentioned allegation and deliver findings. LPA met with Executive Director Tammy Chavez to discuss the purpose of the visit. The investigation consisted of file review, interviewing relevant parties as well as observation.

The allegation indicates that Facility has mold in clients bathroom – Based on LPA’s observation, Room #’s 146,117,126,123 has evidence of mold in the bathroom shower at the time of visit.

Based on observation, the preponderance of evidence standard has been met, therefore, the allegations are substantiated under the California Code of Regulations (Title 22, Division 6 Chapter 1).

An exit interview was conducted where this report, LIC9099, LIC9099D along with appeal rights, were provided to the Executive Director Tammy Chavez.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
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 4
Control Number 56-AS-20260401114051
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: 04/08/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/08/2026
Section Cited
CCR
80087(a)
1
2
3
4
5
6
7
Title 22, Division 6Chapter 1
80087(a) Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.This requirement is not met as evidence by:
1
2
3
4
5
6
7
Upon observing mold in the client’s bathroom shower, the Executive Director immediately directed maintenance/housekeeping staff to clean the area. LPA later reinspected the bathroom and confirmed it was clean and free of mold.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with the section cited above by not ensuring that the clients bathroom shower is free of mold, which poses an immediate health, safety or personal rights risk to persons 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: 04/08/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
04/01/2026 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20260401114051

FACILITY NAME:JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITYFACILITY NUMBER:
365530119
ADMINISTRATOR:TAMMY CHAVEZFACILITY TYPE:
735
ADDRESS:22325 BARTON RD.TELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:150CENSUS: 132DATE:
04/08/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tammy Chavez, Executive DirectorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is not kept clean
Clients items are being stolen
Facility air conditioner does not work
Facility is not kept in good repair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/8/2026 at 10:00 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 residents as well as facility observation.

Allegation #1: Facility is not kept clean– Based on interview with clients and staff it was revealed that the housekeeping staff cleans the client bedroom once a week. LPA observed that the facility hallways and the common areas are clean. LPA was unable to corroborate the allegation.

Allegation #2: Clients items are being stolen- Based on interviews with clients, all of them reported that there were no personal items being stolen from their rooms. Staff revealed that the client’s bedroom doors are always locked and they need a key to access the room. If the door is broken, they will replace it and the lock will be rekeyed. 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: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20260401114051
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: 04/08/2026
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
Allegation #3: Facility air conditioner does not work – Based on observation all the bedrooms air conditioning (AC) system are in good repair. Interviews with clients revealed that their AC is working properly.

Allegation #4: Facility is not kept in good repair – Based on observation the facility sliding doors screen are in good repair. Interviews with clients and staff revealed that if they reported anything that is broken in the facility maintenance will come and fix it.

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 and LIC9099C were discussed and provided to executive director Tammy Chavez.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4