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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530119
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:16:12 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
06/03/2025 and conducted by Evaluator Eldin Serrano
COMPLAINT CONTROL NUMBER: 56-AS-20250603131817
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: 119DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Tammy Chavez, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff are mismanaging resident's medication
Staff are preventing residents from selecting their own doctor
Staff did not safeguard resident’s personal belongings
Staff do not ensure resident appliances are in good working condition
Staff do not ensure the facility is free of mold
Facility is malodorous
INVESTIGATION FINDINGS:
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On 6/05/2025 at 10:00 AM, Licensing Program Analyst (LPA) Eldin Serrano made an unannounced visit to the facility to 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 staffs and residents as well as facility observation.

Allegation #1: Staff are mismanaging resident's medication – Based on interviews, 9 out 9 clients and 2 out 2 staff stated that the staff are managing the client’s medication correctly.

Allegation #2: Staff are preventing residents from selecting their own doctor - Based on interviews 9 out 9 clients and 2 out 2 staff stated that the client can select the doctor that the client chooses to work with unless the client is conserved then the conservator makes that decision. Interviews conducted with facility staff and residents were 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: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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-20250603131817
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: 06/05/2025
NARRATIVE
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Allegation #3 Staff did not safeguard resident’s personal belongings - Based on interviews, 9 out 9 clients and 2 out 2 staff stated that their belongings are safely guarded in their room, and nothing is lost or stolen. Information received during the investigation did not corroborate with the allegation.

Allegation #4 Staff do not ensure resident appliances are in good working condition – Based on observation and interview 9 out of 9 clients and 3 out of 3 staff stated that their appliances are in good working condition. LPA and the maintenance director observed that client #1 (C1) refrigerator is in good working condition. Evidence does not corroborate with the allegation.

Allegation #5 Staff do not ensure the facility is free of mold – Based on observation and interviews 9 out 9 clients and 3 out 3 staff stated that the facility is free of mold. LPA and the maintenance director inspected C1’s room and check the cabinets under the sink and found no evidence of mold. LPA unable to collaborate the allegation.

Allegation #6 Facility is malodorous – Based on observation and interviews 9 out 9 clients and 3 out 3 staff stated that the facility does not have a bad smell or foul odor. Based on the facility policy, smokers are allowed to smoke on the designated smoking area only and not allowed to smoke inside the building. LPA also observed that the facility has the automatic air freshener all over the facility.

Information received during investigation did not corroborate with the allegation.

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 and LIC9099C were discussed and provided to Executive Director Tammy Chavez.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Eldin Serrano
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2