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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530119
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:31:19 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
10/24/2024 and conducted by Evaluator Eldin Serrano
COMPLAINT CONTROL NUMBER: 56-AS-20241024145539
FACILITY NAME:JC WALLACE HOUSE ADULT RESIDENTIAL COMMUNITYFACILITY NUMBER:
365530119
ADMINISTRATOR:ELEINA RIDOLFIFACILITY TYPE:
735
ADDRESS:22325 BARTON RD.TELEPHONE:
(909) 420-0153
CITY:GRAND TERRACESTATE: CAZIP CODE:
92313
CAPACITY:150CENSUS: 100DATE:
10/29/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Tammy Chavez, Client Care DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff are mismanaging resident's P&I
INVESTIGATION FINDINGS:
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On 10/29/2024 at 12:30 PM, Licensing Program Analysts (LPAs) Eldin Serrano and Mary Rico arrived at the facility to investigate a complaint and deliver the findings for the above complaint allegation. Upon arrival, LPAs met with Resident Care Director (RCD) Tammy Chavez, and LPAs informed RCD Chavez of the purpose of the visit. The investigation consisted of file review, interviews with staffs and clients as well as observation.

The investigation was conducted by LPAs Serrano and Rico. The investigation consisted of records review and interviews with relevant parties. The allegation indicated that Staffs are mismanaging resident's P&I. During the investigation, LPAs did not find evidence 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: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
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-20241024145539
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: 10/29/2024
NARRATIVE
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Interviews with eight (8) of eight (8) clients indicated that there is no money stolen and the staffs are not stealing clients money. Clients interviewed reported that the money can only be accessed and claimed through the business officer. P&I is distributed every Thursday of each week. Interviews with two (2) of two (2) staffs indicated all the resident received the P&I based upon the conservator's authorization. In addition, two (2) out of the two (2) staff stated that have have not denied clients money. Futhermore, LPAs Serrano and Rico audited 8 clients P&I and verified clients money matches the facility documentation.

Based on the evidence, the allegation that Staff are mismanaging resident's P&I is 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 with this report, LIC9099 was discussed and provided to Residence Care Director Tammy Chavez.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC9099 (FAS) - (06/04)
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