197607012-2-2-2021-31-AS-CHAS-BZDSVT-20210323141317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607012
Report Date: 02/02/2021
Date Signed: 02/02/2021 04:15:19 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/29/2021 and conducted by Evaluator Wendell Smith

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20210129145636

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: 5	DATE:	02/02/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Josephine Miranda		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Residents are not treated with dignity and respect.
Facility did not post Ombudsman poster.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Wendell Smith finished a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically and through face-time with Josephine Miranda.

Residents are not treated with dignity and respect
It is alleged that the administrator pulled resident #1(R1) by their shirt to attempt to get them to sit down. It is also alleged that administrator ignored a resident using their call button due to them always using it. It was also alleged that administrator ignored a resident who was trying to speak with them. LPA conducted interviews with the administrator regarding the allegation. During the virtual tour LPA attempted to interview residents but due to their medical diagnosis they were not able to answer any questions. LPA was able to gather information from a witness to the allegations which took place on 1/26/2021. Based on the information obtained through

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021

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-20210129145636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.	FACILITY NUMBER: 197607012
	VISIT DATE: 02/02/2021

NARRATIVE

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interviews this allegation is deemed Substantiated at this time. Administrator admitted to trying to get R1 to sit down even though R1 did not want to sit down at the time. Administrator also admitted to ignoring a resident who was pushing their call button due to them using it all day and not knowing to use it only during emergency situations.

Facility did not post Ombudsman poster.
It is alleged that the facility did not have the Ombudsman poster. During the virtual tour LPA did not observe any Ombudsman poster. Administrator stated the one they had, had gotten old and she got rid of it. She stated she asked the Long Term Care Ombudsman to mail her a new one. LPA explained that she should not have discarded the old one until a replacement was available. Based on the information obtained through interviews and observation this allegation is deemed Substantiated. Deficiencies cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted. Copy of report emailed for signature.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20210129145636

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 02/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/05/2021 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will sign a declaration that she will ensure residents rights are protected and observed at all times and to the best of her ability. Signed declaration will be sent to LPA.
	8 9 10 11 12 13 14	Based on information obtained through interviews administrator failed to treat multiple residents with respect by violating R1's personal space, and not listening to other residents needs. This poses a health and safety risk to residents in care.	8 9 10 11 12 13 14
Type B 02/05/2021 Section Cited CCR 87468.2(a)(10)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities The licensee shall post the telephone numbers and addresses for the local offices of the State Department of Social Services and ombudsman program. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will request new Long Term Care Ombudsman poster and until one is obtained by facility will post Long Term Care Ombudsman information in the facility where residents can see and access it. LPA will verify this is done by virtual visit.
	8 9 10 11 12 13 14	Based on information obtained through interview and observation the Local Long Term Care Ombudsman poster was not posted in the facility. This poses a health and safety risk to residents in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell Smith	TELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2021

LIC9099 (FAS) - (06/04)

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