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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 05/07/2025
Date Signed: 05/07/2025 05:06:23 PM

Document Has Been Signed on 05/07/2025 05:06 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JBM RESIDENCE HOME, INC.FACILITY NUMBER:
197607012
ADMINISTRATOR/
DIRECTOR:		JOSEPHINE B. MIRANDAFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
05/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Josephine Miranda - LicenseeTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20250429144827. LPA met with the Licensee and explained the reason for the visit.
  • Review of R2's and resident #5 (R5's) Physician's Reports revealed their ambulatory status as bedridden. Review of the facility sketch revealed only bedroom #3 can retain a bedridden resident. R5 is in bedroom labeled #3 according to the facility sketch. R2 in not in a bedroom cleared for bedridden.
  • Prohibited health condition for resident #3 (R3). R3, Licensee and wound care agency staff confirmed resident has a wound. According to the wound care agency staff it is a stage 4. LPA was not provided documentation or a care plan or exception letter requesting to retain resident. R1 may also have a wound. LPA requested Home Health documentation.
  • While conducting the physical plant tour LPA observed three (03), Resident #1 (R1), R2 and R5 have "full" bed rails. LPA observed the bed rails extended the entire length of the beds. According to Josephine only Resident #2 (R2) is receiving Hospice services.
  • While reviewing resident records LPA did not observed a Pre-Admission Appraisal for R1 and R2. R1 was missing a Physician's Report with tuberculosis (TB) test results. According to Josephine the LIC602A form was provided to R1's doctor and the facility is waiting for it to be completed and returned.
  • Josephine provided an updated LC500 to LPA. Review of staff #1's (S1's) record revealed they do not have a health screening with TB results. According to Josephine S1 last worked on Monday, May 5th 2025.
  • During physical plant tour LPA passed by room labeled #1 and it had a urine odor coming from inside the bedroom. According to wound care agency staff they agreed the room smelled of urine.
  • At 4:30 p.m., LPA observed Licensee changing a resident's soild undergarments without gloves.
Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report provided.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 05/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
N LA & CEN COA AC/SC, 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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2025
Section Cited
CCR
87202(a)(2)

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(a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(2)Bedridden persons. This requirement is not met as evidenced by:
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The Licensee will ensure that the facility is in compliance with the fire clearance approved by the city or county fire department at all times. The Licensee will submit a written plan of action that will be implemented to ensure that the facility comes back into compliance by 5/09/2025 and
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Based on observation and record review the licensee did not comply with the section cited above in that the facility has fire clearance for one bedridden resident and the facility currently has two bedridden resdients which poses an immediate health, safety or personal rights risk to persons in care.
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Licensee will submit an LIC200 and updated facility sketch to obtain a bedridden fire clearance if they decide to retain a second bedridden resident.
Type A
05/08/2025
Section Cited
CCR87608(a)(5)(B)

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(a) ...Postural supports may be used under the following conditions. (5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
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Licensee will remove bed rails that extend the entire length of the bed for R1 and R5 and send a picture to LPA by POC due date 05/08/2025.
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Licensee did not comply with the section cited above by utilizing full bed rails for R1 and R5 who are no longer on hospice which indicates the need which poses an immediate health, safety personal rights risk .
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Half bed rails may be obtained if a written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025

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
N LA & CEN COA AC/SC, 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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
CCR
87458(a)

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87458(a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. This requirement is not met as evidenced by:
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Licensee states R1's doctor has the form and is waiting for it to be completed and provided. Licensee will provide a statement of understading regarding the regulaton cited and submit to LPA by POC due date 05/16/2025.
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Based on record review the licensee did not comply with the section cited above in that the facility did not obtain a medical assessment with TB test for R1 prior to admittance which poses an immediate health, safety or personal rights risk to persons in care.
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 Licensee will obtained and a copy of R1's medical assessment/Physician's Report (LIC602A) with TB test results and will submit a copy as proof of correction.
Type B
05/16/2025
Section Cited
CCR87457(c)(1)(A)

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(c) Prior to admission a determination of the prospective resident's suitability...
(1) The appraisal shall document, at a minimum:(A)An evaluation of the prospective resident's functional capabilities...This requirement is not met as evidenced by:
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The Licensee will complete the appraisal forms for R1 and submit a copy of the forms to LPA by POC due date 5/16/2025.
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Licensee did not comply with the section cited above in two out of five resdients had no preplacement appraisal on file which poses a potential health, safety or personal rights risk to persons in care.
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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.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025

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
N LA & CEN COA AC/SC, 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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/16/2025
Section Cited
CCR
87303(a)

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(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Licensee will make sure that the residents rooms are free of odors and sanitary at all times. Licensee will submit a plan to LPA for how the facility will return and remain in compliance by POC due 05/16/2025.
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Based on observation the licensee did not comply with the section cited above in that LPA smelled a urine odor in bedroom #1 and the section of the facility where the bedroom is located by the formal dining area smelled of urine which poses a potential health, safety or personal rights risk to persons in care.
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Type B
05/16/2025
Section Cited
CCR87412(a)(11)

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(a) The licensee shall ensure that personnel records are maintained on... each employee. Each personnel record shall contain the following information:(11)A health screenings specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by:
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Licensee stated she will not return to work until health screening with TB is completed. Licensee will provide a copy S1's health screening with TB test results by POC due 05/16/2025.
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Based on record review the licensee did not comply with the section cited above in that staff #1's (S1's) record was incomplete missing health screening and TB test result which poses a potential health, safety or personal rights risk to persons in care.
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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.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025

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
N LA & CEN COA AC/SC, 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: 05/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2025
Section Cited
CCR
87615(a)(1)

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(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:
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Resident expressed they do not wish to live anywhere else at this time but will eventually like to live somewhere else. Licensee will submit an exception letter to CCLD to retain resident with a prohibited health condition.
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Based on record review and interviews the licensee did not comply with the section cited above by retaining R3 who is not receiving hospice services and has a stage 4 wound which poses an immediate health, safety or personal rights risk to persons in care.
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Licensee will request Wound Care Plan from wound care agency and submit it to LPA by POC due date 05/08/2025.
Type B
05/16/2025
Section Cited
CCR87470(4)(A)(3)

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(4) All facility staff and volunteers shall use gloves...(A)Gloves shall always be worn when: 3...assisting with incontinence when there is a risk of contact with blood, body fluids or other potentially infectious material. This requirement is not met as evidenced by:
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Licensee will take vendorized training on infection coltrol porocedures and submit certificate of completion to LPA by POC due date 05/16/2025.
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Based on observation LPA Rios observed the Licensee change a resident without using gloves, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104

DATE: 05/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2025

LIC809 (FAS) - (06/04)
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