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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 07/13/2026
Date Signed: 07/13/2026 12:27:01 PM

Document Has Been Signed on 07/13/2026 12:27 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: 1DATE:
07/13/2026
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Josephine B. Miranda - LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Evelin Rios arrived to this facility to conduct and unannounced POC visit for citations issued on 07/03/2026. LPA rang the door bell and was greeted by the Licensee. Licensee granted access. LPA informed Licensee the purpose of the visit.

LPA was informed that Resident #2 (R2) was "discharged" from the facility on Friday, July 10, 2026 and admitted to a new assisted living facility. LPA obtained a copy of a signed document by R2's responsible person (RP) dated July 10, 2026. According to the Licensee on 07/04/2026 she verbally informed R2's and Resident #1's (R1's) RPs the facility would be closing. Licensee did not provide the residents or their RPs the required 60 day written eviction notice. The Licensee states a written eviction notice would still be provided to residents' RPs. The Licensee informed LPA, R1 will be discharged from the facility today, July 13, 2026. According to the licensee the decision to transfer the residents out were made by the residents' RPs before a written eviction notice could be provided. LPA contacted R1's and R2's, RPs and was informed that a 60 day written notice was not provided to them.

Original Citations and POC's with results of the POC visit are as follows:



H&S Code 1569.605: The licensee did not obtain liability insurance. POC: The licensee will obtain liability insurance by 07/06/2026. POC was not cleared. The licensee stated the Insurance Broker was not able to assist with obtaining Liability Insurance as facility's application was denied. Licensee is forfeiting their license.
(Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/13/2026
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: 07/13/2026
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87465(h)(5) Incidental Medical and Dental Care Services / Resident's medication was transferred from one bottle to another. POC: 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 07/04/2026. POC was not cleared. Licensee contacted R1's RP requesting a medication refill. Licensee is closing facility.

87465(e) Incidental Medical and Dental Care Services / 2 out of 2 residents did not have a physician order for their medication. POC: The Licensee will obtain prescription orders from the residents' physicians by POC due date 07/10/2026. R2 is no longer in the facility. Licensee provided LPA a copy of physician's order for R1's medication. POC cleared today.

87463(a) Reappraisals / 2 out of 2 residents not having reappraisals once every 12 months or as necessary. POC: The licensee will update resident appraisals for both residents and send a copy to the department by POC 07/10/2026. Licensee provided LPA with re appraisals for R1 and R2. POC cleared today.

H&S Code 1569.695(c) / The licensee did not conduct a quarterly emergency drill on each shift. POC: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 07/10/2026. POC not cleared. Licensee will close facility.

H&S Code 1569.618(a) / The administrator has not been present at the facility during normal working hours in the last month. POC: 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 07/17/2026. Due to the facility's closure POC will not be provided. According to the Licensee the Administrator has not been to the facility.

LPA conducted a physical plant tour and observed R2 was no longer in the facility.

Exit interview conducted. Deficiency cited. Refer to LIC 809-D. Copy of appeal rights and a copy of report provided to Licensee.
NAME OF LICENSING PROGRAM MANAGER: Mary G Flores
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2026 12:27 PM - It Cannot Be Edited


Created By: Evelin Rios On 07/13/2026 at 11:41 AM
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: 07/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/14/2026
Section Cited
CCR
87224(a)(5)(A)(1)

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87224 Eviction Procedures (a) The licensee may evict a resident for ... (5) Change of use of the facility. (A) ... sixty (60) days written notice, evict ... 1. ... written notice ... shall be made to the resident or the resident’s responsible person ... This requirement is not met as evidenced by:
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Licensee is moving forward with forfeiture of license. Licnsee will provide 60 day written eviction notices to RPs and submit copy of notice to the department.
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Based on interviews, the licensee did not comply with the section cited above in not providing resident R1 and R2 and their responsible person(s) a proper 60 day written eviction notice 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.
Mary G Flores
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2026


LIC809 (FAS) - (06/04)
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