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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 07/03/2026
Date Signed: 07/03/2026 04:38:46 PM

Document Has Been Signed on 07/03/2026 04:38 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JBM RESIDENCE HOME, INC.FACILITY NUMBER:
197607012
ADMINISTRATOR/
DIRECTOR:		DIVINA L. HEIDELBERGFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 2DATE:
07/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Josephine B. Miranda - LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct and unannounced annual required visit. LPA rang the door bell and was greeted by the Licensee. Licensee granted access. LPA informed Licensee the purpose of the visit. This is an Residential Care Facility for the Elderly (RCFE), with an approved fire clearance for (6) non-ambulatory residents of which one (1) can be bedridden for a total capacity of six (6). The facility is a single story building with six (6) bedrooms and three (3) bathrooms.

At approximately 9:20 a.m., LPA conducted a physical plant tour of the facility, both inside and outside, and observed the following:

There is only one entrance being utilized at the facility. At the entrance LPA observed a visitor sign-in log and hand sanitizer. LPA observed required postings through out the facility.

Common areas were observed clean and surfaces were clear of clutter. The dining area was observed with a table and chairs that sit the capacity of the facility. The living room was observed to be properly furnished with couches and recliner. The fireplace was observed not in use and covered with a screen inaccessible to residents.

The kitchen was observed to have a sufficient amount of (2) days perishable and seven (7) days non-perishable food. Kitchen area was observed clean and free of pests. Knives and sharps were observed to be locked in a kitchen drawer inaccessible to residents. Kitchen appliances, the refrigerator, stove, dishwasher and microwave were observed functioning properly. The fire extinguisher located by the the kitchen was fully charged. (Continued on LIC 809-C)
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2026
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: JBM RESIDENCE HOME, INC.
FACILITY NUMBER: 197607012
VISIT DATE: 07/03/2026
NARRATIVE
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LPA observed two facility telephones. telephones were tested, and both were functioning properly. In the hallway leading to bedroom #3, #4 and #5, LPA observed a closet with extra linens. Hallways and passageways were lighted appropriately.

The facility has five (5) bedrooms for resident use and one (1) staff room for live-in staff. The bedrooms have the required furniture, lighting and storage. Bedroom #5 can be shared. Exit doors in bedrooms were opened to test auditory alarms. LPA observed the auditory alarms were on and functioning properly.

The bathrooms were checked for cleanliness and proper operation. Under sink cabinets are used to store cleaning supplies and were observed locked. The hot water temperature was measured in all bathrooms and read within regulations between 105.1°F and 105.4°F.

The laundry room is accessible located near bedroom #4 and leads to the attached garage. Laundry detergents, cleaning agents, and other toxins are stored in a locked cabinets in the laundry room. The attached garage is accessible through the laundry room. The door leading to the garage was locked and the garage is being utilized for extra storage.

The backyard of the facility is fenced in equipped with a patio and outdoor furniture for residents. Outdoor passageways were clear of obstructions. No bodies of water observed.

Facility records are kept in a cabinet by the kitchen. At 11:05 a.m., LPA reviewed two (2) of two (2) resident records. Both residents do not have annual reappraisal on file or documentation indicating refusals to participate.

Medications and first aid kit are kept locked in a kitchen cabinet. LPA observed a First-aid kit. LPA observed medication for residents no longer in the facility that had expired on 2022 and 2023. According to the Licensee the family members never picked it up. LPA along with the licensee reviewed two (2) of two (2) residents' centrally stored medication and their centrally stored medication records for accuracy.
(Page 2 of 3)
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: JBM RESIDENCE HOME, INC.
FACILITY NUMBER: 197607012
VISIT DATE: 07/03/2026
NARRATIVE
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Review of Resident#1's (R1's) medication and medication records revealed their Levothyroxine bottle has an expiration date of 12/09/2025 and had more then it's 30 pill quantity indicated on the bottle. According to the Licensee they had poured the new medication into the old medication bottle to save space. R1's Banophen label states "as needed". According to the licensee she has been giving it to the resident every day. Licensee believes the doctor made a mistake on the order. According to the Licensee, the resident has needed the medication every day. The quantity on the bottle is 15 and LPA counted 5 pills. LPA review of the facility's Medication Administration Record (MAR) and it indicated they had not documented the 10 pills given to R1. LPA requested to see the PRN authorization form. According to the Licensee they do not have one and will be requesting one from the doctor. R1's, Hydrocodone label directs to take half a tablet by mouth 2 times a day. Centrally Stored Medication Records revealed it was started on 06/13/2026. LPA observed only 15 half tablets have been provided since it started. According to the licensee they did not give the second dose to R1 because they were sleeping.

LPA reviewed four (4) of four (4) staff records. LPA contacted the Administrator, Divina Heidlberg and left a voicemail for a return call. According the Licensee, they last spoke to the Administrator over the phone last month and she couldn't remember when the Administrator last worked in the facility. LPA's review of the staff weekly schedule indicated Administrator was scheduled 2 hours a day from Monday to Friday. Emergency Disaster Plan (610E) had not been updated. LPA was not provided documentation of quarterly emergency disaster drills conducted within the past year. According to the Licensee she had not conducted the training.

The Licensee has not obtained liability insurance. According to the Licensee they have gone to different insurance companies but they will not approve an application for liability insurance. The licensee stated they will be closing the facility to retire. The licensee will provide proper notification to residents and their responsible parties by next week. Licensee will send a copy of the notification within the time frame required to the Department.

LPA observed smoke/carbon monoxide detectors through out the facility. LPA observed the Licensee test the smoke alarm and it was functioning properly.

Deficiencies observed during todays visit. Refer to LIC809-D. Exit interview conducted, Appeal Rights and a copy of this report was provided to Licensee.
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2026
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 07/03/2026 04:38 PM - It Cannot Be Edited


Created By: Evelin Rios On 07/03/2026 at 03:52 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: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.605
Other Provisions
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 interview and record review, the licensee did not comply with the section cited above in not obtaining liability insurance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/03/2026
Plan of Correction
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The licensee will obtain liability insurance by POC due date 07/006/2026
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

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 one (1) out of two (2) resident's medication being transferred from one bottle to another which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/04/2026
Plan of Correction
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The licensee will contact R1's physician and request a refill of the medication. Licensee will conduct vendorized training regarding medication and provide copy registration to training to the department 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 07/03/2026 04:38 PM - It Cannot Be Edited


Created By: Evelin Rios On 07/03/2026 at 03:52 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: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in the administrator has not been present at the facility during normal working hours in the last month which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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The licensee will complete time sheets when the administrator is present at the facility for the next two weeks and provide time sheets to the department by POC due date.
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 residents not having physician orders for their medication which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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The Licensee will obtain prescription orders from the residents' physicians 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 07/03/2026 04:38 PM - It Cannot Be Edited


Created By: Evelin Rios On 07/03/2026 at 03:52 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: 07/03/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 2 out of 2 residents not having reappraisals once every 12 months or as necessary which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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The licensee will update resident appraisals for both residents and send a copy to the department by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in not conducting quarterly emergency drill each shift which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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The licensee will conduct two emergency drills, one for earthquake and one for fire for every shift and send documentation of completion with staff names for each shift completed to the department 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2026


LIC809 (FAS) - (06/04)
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