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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607012
Report Date: 09/22/2025
Date Signed: 09/22/2025 04:33:54 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
09/17/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250917093042
FACILITY NAME:JBM RESIDENCE HOME, INC.FACILITY NUMBER:
197607012
ADMINISTRATOR:DIVINA L. HEIDELBERGFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 2DATE:
09/22/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Josaphine Miranda - LicenseeTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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Unlawful eviction.
Facility staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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On 09/22/2025 Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted an initial complaint visit to investigate the above mentioned allegations. Upon arrival, LPA was greeted by Staff #1 (S1) and was granted access. Inside, LPA met with Licensee, Josephine Miranda and explained the purpose of todays visit. At approximately 9:55 a.m., an entrance interview with the Licensee was initiated.

During the course of the investigation, LPA obtained and reviewed copies of the following: facility's resident roster, Personnel Report (LIC 500), Resident #1's (R1's) admission agreement, R1's pre admission appraisal, R1's resident appraisal, R1's Unusual Incident/Injury Report, R1's Home Health documentation, R1's Physician Orders for Life-Sustaining Treatment (POLST), text messages exchanged between R1’s responsible person and the Licensee from 09/12/25 to 09/13/25, and a voicemail message left for the Licensee by R1’s responsible person on 09/12/25.
(Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
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 4
Control Number 31-AS-20250917093042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/22/2025
NARRATIVE
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(Continued from LIC9099) At approximately 10:21 a.m., LPA Rios conducted a physical plant tour of the facility. During the tour, LPA observed that R1 was not in the facility, Resident #2 (R2) and Resident #3 (R3) were asleep. No health or safety issues were observed at this time. Prior to today’s visit, LPA Rios conducted telephone interviews with R1’s responsible person and R1’s assigned Licensed Clinical Social Worker (LCSW), who is assisting with R1’s placement.

Allegation: Unlawful eviction. It was alleged that the facility would not be accepting R1 after hospital discharge. To investigate this allegation, LPA conducted an interview with the Licensee and was informed that they had spoken to R1's LCSW sometime last week regarding R1's discharge and return to the facility. The Licensee confirmed they informed R1's LCSW that upon discharge they would not be admitting R1 due to R1's "unstageable" wounds and that she could not admit R1 because they were not allowed to take care of someone with "unstageable" wounds per Community Care Licensing (CCL). LPA's review of R1's Home Health services for wound care confirmed R1 had been receiving care for a wounds since 05/22/25 after being admitted to the facility on 04/12/25. On 08/11/25, an unannounced Case Management – Deficiencies visit was conducted. During the visit, the facility was cited for retaining R1, who had a prohibited health condition. As part of the plan of correction, the Licensee submitted an exception request to retain R1 at the facility. Licensee had not received a approval or denial from CCL. Upon LPA’s request, the Licensee could not provide R1's re appraisal regarding changes in the level of care. Additionally, the investigation revealed the Licensee did not serve R1 or their responsible person a written 30-day Eviction notice.

On 09/17/25, a telephonic interview with R1's responsible person revealed that they had anticipated R1 going back, and had conversations with the licensee about making their monthly payment on 09/14/25 however, on the 09/16/25, R1's LCSW informed R1's reasonable person that the Licensee stated R1 requires a higher level of care. No re-appraisal and no conversation with R1's responsible person was done by the facility's Licensee to inform that the facility can no longer meet R1's needs. On 09/17/25, a telephonic interview with R1's, LCSW revealed they had made contact with the licensee to arrange R1's return when the Licensee informed them they would not be taking R1 back due to R1's Stage 3 wound and Licensing. Licensee also asked the LCSW to help with placement. Based on interviews and record review this allegation is Substantiated at this time.

(Continue to LIC9099-C) Page 2 of 3
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20250917093042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2025
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis... This requirement is not met as evidenced by:
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Licensee agreed to complete training on the regulation cited from a consultant. Licensee will provide the name of the consultant and training information along with the date the training is scheduled to LPA by POC due date 09/23/2025.
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Based on interviews the licensee failed to call 911 immediately after the licensee suspected R1 had a "mini stroke" on 09/12/25 at approximately noon and waited to call 911 on 09/13/25 at approximately 11:00AM, which posed an immediate health and safety risk to residents in care.
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Licensee will send a copy of the training completion certification to LPA.
Type A
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Section Cited
CCR
87224(a)
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Eviction Notification (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required... This requirement is not met as evidenced by:
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According to R1's responsible person, R1 will not be returning to the facility. Licensee agreed to complete training on the regulation cited from a consultant. Licensee will provide the name of the consultant and training information along with the date the training is scheduled to LPA by POC due date 09/23/25.
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Based on interviews the licensee failed to reassess R1 and failed to provide a 30 days written eviction notice to R1 and/or their responsible person, which posed an immediate health and safety risk to residents in care.
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Licensee will send a copy of the training completion certification to LPA.
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: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20250917093042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/22/2025
NARRATIVE
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(Continued from LIC9099-C) Allegation: Facility staff did not seek medical attention in a timely manner. It was alleged that the Licensee informed R1's family that R1 may have had a "stroke" but did not call 911 until the next day. To investigate this allegation, LPA conducted an interview with the Licensee and was informed that around noon of 09/12/25 R1's family member in the presence of R1's Home Health nurse asked the Licensee why R1 was "screaming" and complaining of pain when they attempted to stretch out R1's left arm which was bent at the elbow.

According to the Licensee and a review of text messages, the following is a representation of the events that occurred: On 09/12/25, the Licensee informed R1’s family member that they believed the contractions in R1’s arm and leg could be due to a “mini stroke.” According to the Licensee, R1’s family member appeared anxious and contacted R1’s responsible person. R1’s responsible person then reached out to the Licensee same day via telephone, sending a text message at 6:05 p.m., followed by a voicemail at 6:21 p.m., requesting that the Licensee call 911 if they believed R1 was experiencing a stroke. At approximately 8:27 p.m., the Licensee followed up with R1’s responsible person to clarify that they suspected R1 may have had a “mini stroke” that had gone unnoticed. When asked by the LPA why they believed R1 had experienced a "mini stroke", the Licensee explained that they had observed contractions in R1’s leg and now arm and asked their friend in the neurology field, who suggested there are different reasons but according to the Licensee their friend said based on the resident's age an symptoms it could indicate a stroke. The Licensee stated that they chose not to immediately call 911 because they wanted to monitor R1 and contact R1’s Home Health provider. However, since the provider was closed at that time, they waited until the next morning. On 09/13/25, at approximately 8:00 a.m., the Licensee contacted Home Health, who advised that if the Licensee believed R1 had suffered a stroke, they should call 911. Licensee admitted that they did not call 911 immediately after Home Health because they were gathering R1’s documentation to provide to the EMT. 911/Paramedics arrived to the facility at approximately 11:00 a.m.

On 09/17/25, LPA Rios confirmed with R1’s Licensed Clinical Social Worker (LCSW), and later on 09/22/25 with R1’s responsible person, that R1 did not experience a stroke. However, the Licensee believed R1 had symptoms consistent with a stroke and still delayed seeking medical attention. Based on the information obtained this allegation is deemed Substantiated at this time.

Deficiencies cited on LIC9099-D. Exit interview conducted, appeal rights explained and copy of this report signed and delivered. Page 3 of 3
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4