197607012-8-20-2025-31-AS-MGFS-DVU2ND-20260709173232

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607012
Report Date: 08/20/2025
Date Signed: 08/20/2025 04:36:04 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/12/2025 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20250812100818

FACILITY NAME:	JBM RESIDENCE HOME, INC.		FACILITY NUMBER:	197607012
ADMINISTRATOR:	JOSEPHINE B. MIRANDA		FACILITY TYPE:	740
ADDRESS:	3205 ARIOUS WAY		TELEPHONE:	(661) 522-1968
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 3	DATE:	08/20/2025
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Josephine Miranda		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility does not provide the quality of food necessary to meet residents dietary needs.

INVESTIGATION FINDINGS:

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On 08/20/2025 Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted an initial complaint visit to investigate the above mentioned allegation. Upon arrival, LPA was greeted by Staff #1 (S1) and was granted access. LPA met with Licensee, Josephine Miranda and LPA explained the purpose of the visit. An entrance interview was conducted.

Allegation: Facility does not provide the quality of food necessary to meet residents dietary needs. It is alleged that the licensee stored expired food in the pantry and freezer, failed to serve meals at appropriate times and allowed staff to serve one resident’s leftover food to another. To investigate the allegation, from approximately 11:20 AM, to 12:00 PM, LPA Rios conducted a physical plant tour of the facility and while conducting tour LPA interviewed the licensee and S1. At approximately 12:00 PM to12:42 PM, LPA made observations of S1 cooking and preparing lunch for resdients.
(Continue to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

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 31-AS-20250812100818

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/20/2025

NARRATIVE

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(Continued from LIC9099) From 12:00 PM to 12:30 PM, LPA also reviewed and obtained copies of food purchase receipts, daily menu and food service information from facility's program. From 12:42 PM to 1:22 PM, LPA interviewed one (01) out of three (03) residents residing in the facility and a family member visiting Resident #3 (R3). Resident #1 (R1) was no longer in the facility and not included in today's census. Resident #3 (R3) and Resident #4 (R4) did not respond to LPA's questions. LPA observed residents eating meals. LPA's observation of the refrigerator found that shelves are labeled for residents and for employees. LPA randomly pulled out food from the refrigerator, freezer and pantry and observed they were not past best by dates or expiration dates. Employee's food was in containers with no date but did not smell or look spoiled. There is a second refrigerator in the backyard and according to the licensee it is only meant for staff.
LPA's interview with R2 did not corroborate the allegation. R2 provided limited answers, primarily 'yes' or 'no' and did not elaborate on answers. LPA's interview with R3's family member, revealed they visit R3 often at different times and makes it a point to visit when breakfast is being served and again at a later time during the same day. According to R3's family member the meals are served on time, look good and R3 eats well. LPA's interview with staff deny the allegation. Interview with S1 revealed R1 preferred to prepare their own meals which staff supervised and provided assistance when needed. S1 further stated that R1 would request breakfast be served at 4 AM. Interview with the licensee revealed they purchased specific food R1 requested and had to provide a notice posted on the dining room wall about reasonable meals times. There was not enough evidence to corroborate the allegation. Therefore, Based on interviews, and observations this allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025

LIC9099 (FAS) - (06/04)

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