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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 05/21/2025
Date Signed: 05/21/2025 05:11:20 PM

Document Has Been Signed on 05/21/2025 05:11 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: 4DATE:
05/21/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Josephine MirandaTIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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At 12:30 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the above mentioned facility to conduct an unannounced annual inspection. LPA was greeted by Licensee, Josephine Miranda and staff #1(S1). LPA explained the reason for the visit. An entrance interview was conducted.

At 12:45 p.m., LPA toured the facility inside and outside and observed the following:

Upon entry LPA observed appropriate postings except for the Complaint Poster (PUB 475) or a poster created by the facility with the same information. LPA provided a an email link to PUB 475 to Licensee. The facility has six (06) total bedrooms and three (03) total bathrooms.

Five (05) out of the six (06) bedrooms are for residents' use of which one (01) is shared. Bedrooms have appropriate furniture such as beds, night stands, chairs and enough storage for residents' belongings. In bedroom labeled 4, LPA observed an extra bedframe with mattress leaning against the wall on the left side of the resident's bed. According to Josephine the resident would be transferred to the newer furniture and a company would be by to pick up the extra furniture. LPA observed auditory alarms on exit doors working properly. Bathrooms were observed clean and were supplied with toilet paper, hand soap, paper towels, grab bars by toilets and showers and showers had non slip flooring. In the shared bathroom LPA observed boxes of incontinent care stacked on top of each other blocking access to a shower. Licensee stated she and S1 would be moving the boxes to a storage area tonight. At 3:22 p.m. LPA tested the hot water temperature in one (01) bathroom and it read 110.7 degrees Fahrenheit, within regulation.
(Continue to LIC809-C)
Eva MillerTELEPHONE: (818) 596-4373
Evelin RiosTELEPHONE: 424-299-6104
DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 7
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
VISIT DATE: 05/21/2025
NARRATIVE
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(Continued from LIC809) The laundry room was observed locked and leads to the attached garage. In the laundry room LPA observed a washer and dryer. The facility keeps cleaning supplies and detergents locked in the garage.

Common areas include the living room, dining area and backyard. In the living room LPA observed a television with appropriate furniture that sits the capacity of the facility. Dining areas had appropriate tables and chairs. LPA observed two (02) facility telephones, operational. The backdoor in the living room area leading to the backyard is missing a door knob. The facility has attached two strings, one on the inside of the door and the other on the outside to open and close the door. According to the Licensee she is working on getting it fixed. The backyard is fenced in and LPA observed a covered patio with outdoor furniture and a shed that is kept locked. Outside LPA also observed a refrigerator used to store extra food and a non working refrigerator, washer and dryer. According to Josephine the appliances are used for storage but will be working on removing them from the property. Exits and passageways were observed free of obstructions.

The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. There is a one (01) week supply of nonperishable, and two 02) day supply of perishable food. LPA observed one (01) fire extinguisher fully charged. LPA observed a first aid kit and resident medications in a locked kitchen cabinet.

At 2:30 p.m., LPA reviewed four (04) of four (04) resident records and two (02) staff files. At 3:30 p.m., LPA reviewed residents medication and centrally stored medication and destruction records. Medication records for centrally stored medications had not been updated for the month of May 2025 and did not accurately reflect the medication stored for three (03) out of four (04) residents. Licensee stated they were unable to renew the facilities lability insurance. Licensee provided information to change administrator.

Deficiencies were observed, refer to (LIC809-D). An exit interview was conducted. Appeal rights provided. A copy of this report was signed and delivered.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 05/21/2025 05:11 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/21/2025 at 04:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(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:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in the back exterior door leading to the backyard was missing a door knob which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee will submit a picture of the fixed door with a door knob to LPA POC due date.
Type B
Section Cited
CCR
87506(b)(17)(E)
Resident Records
(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above in one (01) out of four (04) resident who do not have a reappraisal and were identified as having a wound which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/26/2025
Plan of Correction
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Licensee will submit a reappraisal for resident #1(R1) by POC due date.
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 Miller
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4373
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 424-299-6104
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 05/21/2025 05:11 PM - It Cannot Be Edited


Created By: Evelin Rios On 05/21/2025 at 04:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/21/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(6)

(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in three (03) out of four (04) residents' medication not being properly recorded with required information which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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The Licensee has agreed to updated Centrally Stored Medication and Destruction Records (LIC622) for each resident as per facility program. Copy of LIC 622 will be sent to LPA by POC due date.
Type B
Section Cited
HSC
1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not maintaining liability insurance which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2025
Plan of Correction
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Licensee will obtain liability insurance and send a copy of certification to LPA by POC due date.
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 Miller
NAME OF LICENSING PROGRAM MANAGER:
TELEPHONE: (818) 596-4373
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
TELEPHONE: 424-299-6104
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/21/2025


LIC809 (FAS) - (06/04)
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