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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 02/06/2021
Date Signed: 02/07/2021 11:43:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JBM RESIDENCE HOME, INC.FACILITY NUMBER:
197607012
ADMINISTRATOR:JOSEPHINE B. MIRANDAFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 5DATE:
02/06/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Josephine MirandaTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Wendell Smith conducted a case management visit. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Josephine Miranda.

The reason for today's visit was information received that on 2/4/21 Long Term Care Ombudsman (LTCO) attempted to conduct a visit to the facility and was denied access to the facility by the administrator. LPA conducted interviews with the administrator regarding this incident. Administrator stated that they did not want to let anyone in the facility due to fear of the Covid virus and that the resident's were sleep. LPA explained to the administrator that they let LTCO in the previous week and there was no issue. LPA explained that if the residents were sleep and did not want to be bothered then they could have let the LTCO in a common area of the facility and to explain the situation. Based on the information obtained through interviews a citation will be issued because denying the LTCO in the facility is a violation of resident's personal rights. Deficiency cited on LIC 809 D. Appeal Rights explained. Exit Interview conducted. Copy of report emailed to administrator for signature.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.
FACILITY NUMBER: 197607012
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2021
Section Cited

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Personal Rights of Residents in All Facilities-
To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.
This requirement was not met as evidenced by:
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Based on information obtained during interviews administrator refused to let LTCO into the facility. This could pose an immediate health and safety issue to all residents in the facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2021
LIC809 (FAS) - (06/04)
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