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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607012
Report Date: 08/20/2025
Date Signed: 08/20/2025 04:52:09 PM

Substantiated


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
04/29/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250429144827
FACILITY NAME:JBM RESIDENCE HOME, INC.FACILITY NUMBER:
197607012
ADMINISTRATOR:JOSEPHINE B. MIRANDAFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 3DATE:
08/20/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Josephine MirandaTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Licensee does not ensure that resident's grooming needs are met
Licensee does not assist resident with ambulating
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced subsequent complaint visit to this facility to deliver determinations on the above allegations. LPA met with the licensee representative Josephine Miranda and explained the reason for the visit.

To investigate the allegations LPA conducted an initial complaint visit on 05/07/2025. During initial visit LPA interviewed the licensee, Josephine Miranda and from 9:50 a.m. – 11:00 a.m., LPA Rios conducted a physical plant inspection. While conducting the facility tour LPA interviewed three (03) out of five (05) residents. Resident #2(R2) was sleeping, and Resident #5 (R5) did not respond to LPA's questions. From 11:00 a.m. to 12:00 p.m., LPA reviewed five (5) resident records and obtained copies, including but not limited to: R1’s Admission Agreement, a handwritten note regarding R1’s health conditions, and an after-visit summary page. LPA also interviewed two (2) relatives of Resident #1 (R1) who were visiting the home.
(Continue to LIC9099-C)
Substantiated
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)
Page: 1 of 5
Control Number 31-AS-20250429144827
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) On a subsequent visit conducted on 05/09/2025, LPA Rios obtained contact information for R1's home health agency. According to the licensee only the contact information could be provided as an assessment was only recently completed. During visit LPA Rios interviewed one (01) staff and re-interviewed the licensee.

On an annual visit conducted on 05/21/2025 LPA reviewed resident's records and obtained copies, including but not limited to: R1's pre placement appraisal, resident appraisal, physician's report, home heath's plan of care, daily menu, weekly bath schedule.

On a subsequent visit conducted on 08/11/2025, LPA conducted a physical plant tour of the facility. During the tour, LPA re-interviewed the licensee, two (2) out of four (4) residents (R1 and R4), and Resident #4’s (R4’s) family member who was visiting at the time. One resident, admitted in June, was not interviewed as they were not present in the facility when LPA arrived.

Allegation: Licensee does not ensure that resident's grooming needs are met. It is alleged that Resident #1 (R1) is not groomed.

Review of Resident #1’s (R1’s) admission agreement confirmed that grooming was an agreed-upon basic service for which R1 required assistance. During the physical plant tour on 05/07/2025, LPA observed that R1 was not wearing socks, allowing for direct observation of R1’s feet. LPA noted that while R1’s feet were clean, the toenails were long, cracked, and chipped. LPA also observed that R1 had long fingernails. During the interview with R1, the resident spoke generally about their experience at the facility but did not provide information specific to the allegation. Review of physician's report on 05/21/2025 confirmed R1 requires assistance with grooming. In an interview with the licensee conducted today, the licensee stated that R1 had been sent to a podiatrist but acknowledged that staff had not clipped R1’s nails. The licensee explained that R1 required a podiatrist, but added that the facility is now addressing the issue and that "everything is good." LPA requested paperwork for podiatrist visit. Licensee to obtain copies from responsible party and provide copies to LPA. Based on LPA’s observations, interviews, and record review, there is sufficient evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Page 2 of 3 (Continue to LIC9099-C)
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)
Page: 2 of 5
Control Number 31-AS-20250429144827
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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Allegation: Licensee does not assist resident with ambulating. It is alleged that resident #1 (R1) is kept in bed.

During the interview with R1, the resident spoke generally about their experience at the facility but did not provide information specific to the allegation. During and interview with the licensee on 05/07/2025 they revealed they and staff do not provide assistance with ambulation because there is no doctor's order in place to do so. Licensee stated they are planning to ask R1's insurance and physician for a hoyer left and geriatric chair because R1 is very heavy for the licensee to move alone and R1 cannot be placed on a regular chair as they may fall forward. Review of physician's report on 05/21/2025 confirmed R1 requires assistance with transferring in and out of bed and is unable to stand or walk on their own. On 08/11/2025 licensee provided LPA a picture of R1 on a geriatric chair in the living room. Based on LPA’s observations, interviews, and review of documentation there is sufficient evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Deficiencies cited (Refer to LIC9099-D). Exit interview conducted. Appeals provided. Copy of report provided.
Page 3 of 3
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)
Page: 3 of 5
Control Number 31-AS-20250429144827
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2025
Section Cited
CCR
87464(f)(1)
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(f) Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by:
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The Licensee has trimmed R1's nails twice as of admission. Submit a grooming schedule for R1 to LPA by POC due date.
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Based on observation and record review, the licensee did not comply with the section cited above in not meeting R1's grooming needs which poses a potential health, safety or personal rights risk to persons in care.
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Type B
09/06/2025
Section Cited
CCR
87464(d)
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(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs...This requirement is not met as evidenced by:
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The Licensee will submit a physical therapy schedule and what the staff at the facility most assist with regarding physical therapy plan to LPA by POC due date.
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Based on interviews and record review, the licensee did not comply with the section cited above in not meeting R1's ambulating needs which poses a potential 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.
SUPERVISOR'S NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5