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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 365530119
Report Date: 06/11/2025
Date Signed: 06/11/2025 11:12:29 AM

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
06/04/2025 and conducted by Evaluator Eldin Serrano
COMPLAINT CONTROL NUMBER: 56-AS-20250604115005
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: 120DATE:
06/11/2025
UNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Tammy Chavez, Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Facility staff spoke inappropriately to resident
Facility staff did not safeguard resident's personal information
Facility staff did not prevent an outside individual from entering the facility and making threats
INVESTIGATION FINDINGS:
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On 6/11/2025 at 10:35 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 clients as well as facility observation.

Allegation #1: Facility staff spoke inappropriately to resident – Based on interviews, 9 out 9 clients stated that no staff talks to them inappropriately. Some clients stated that the staff are respectful and professional. Based on interviews, LPA is unable to corroborate the allegation.

Allegation #2: Facility staff did not safeguard resident's personal information - Based on interviews 9 out 9 clients stated that the staff safeguard their personal information, and it was not shared with anyone. Based on interviews conducted with clients, LPA is 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: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
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-20250604115005
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: 06/11/2025
NARRATIVE
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Allegation #3 Facility staff did not prevent an outside individual from entering the facility and making threats - Based on interviews, 9 out 9 clients and 2 out 2 staff stated that they have no knowledge of any outside individual threatening anyone in the facility. Additional interview with witnesses were unable to be conducted at this time due to unavailability. Information received during the 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: 06/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2