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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530119
Report Date: 12/13/2024
Date Signed: 12/13/2024 12:26:11 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
12/10/2024 and conducted by Evaluator Eldin Serrano
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20241210160232
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: 104DATE:
12/13/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica Roberts, Client Care CoordinatorTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Staff do not ensure the facility is cleaned/sanitized.
Facility is malodorous.
Staff are not keeping residents' information confidential.
INVESTIGATION FINDINGS:
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On 12/13/2024 at 9:00 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility is to conduct the investigation and to deliver the findings of the above allegations. LPA Serrano explained the purpose of the visit to a staff. Staff informed Client Care Coordinator (CCC) of the visit. Client Care Coordinator (CCC) Jessica Roberts met with LPA Serrano and LPA explained the purpose of the visit to CCC. The investigation consisted of file review, interviews with staffs and clients as well as observation.

The investigation was conducted by LPA Serrano. The investigation consisted of records review and interviews with relevant parties. The allegations indicate:

#1 Staff do not ensure the facility is cleaned/sanitized.– Based on observation, clients and staff interview, 10 out of 10 clients and 3 out of 3 staff stated that the facility is cleaned and sanitized.
*** Continuation in LIC9099C ***

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

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
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-20241210160232
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: 12/13/2024
NARRATIVE
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 They stated that housekeeping and maintenance do their daily routine of cleaning and sanitizing the facility including cleaning their room and assisting them with their laundry.

#2 Facility is malodorous - Based on observation, clients and staff interview, 10 out of 10 clients and 3 out of 3 staff stated that they do not smell any unpleasant or offensive odor at the facility. Furthermore, LPA observed that the facility has the air spray in every hallway that keeps the facility smelling clean and fresh in addition to the housekeeping constantly cleaning and sanitizing all the common area and clients room.

#3 Staff are not keeping residents' information confidential. - Based on clients interview, 10 out of 10 clients stated that their personal information are kept confidential by the staff at the facility. The clients stated that every time they talked to staff it is always on a private setting without anyone hearing or knowing about their conversation.

During the 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 Client Care Coordinator Jessica Roberts.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2024
LIC9099 (FAS) - (06/04)
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