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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530119
Report Date: 04/23/2025
Date Signed: 04/23/2025 04:17:20 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
04/17/2025 and conducted by Evaluator Eldin Serrano
COMPLAINT CONTROL NUMBER: 56-AS-20250417142939
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: 111DATE:
04/23/2025
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Tammy Chavez, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff does not treat residents with respect
INVESTIGATION FINDINGS:
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On 4/23/2025 at 2:20 PM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to investigate and deliver the findings of the above allegation. LPA Serrano explained the purpose of the visit to the Executive Director Tammy Chavez. The investigation consisted of file review, interviews with staffs and residents as well as observation.

Regarding allegation Staff does not treat residents with respect – Based on residents and staff interview, 11 out of 11 residents and 6 out of 6 staff stated that the staff in this facility treated everyone with respect. They treat everyone fairly and always attend to their needs. Some of the client stated that the staff go above and beyond their duty.

During the investigation, LPA did not find evidence to corroborate the allegations.

*** Continuation in LIC9099C ***
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
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 2
Control Number 56-AS-20250417142939
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: 04/23/2025
NARRATIVE
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Based on the evidence, the allegation mentioned above 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 where this report, LIC9099, LIC9099C were discussed and provided to Executive Director Tammy Chavez.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2