197607012-1-20-2026-31-AS-MGFS-DW724F-20260720170353

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607012
Report Date: 01/20/2026
Date Signed: 01/20/2026 02:47:33 PM

Unsubstantiated

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
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. MIRANDA		FACILITY TYPE:	740
ADDRESS:	3205 ARIOUS WAY		TELEPHONE:	(661) 522-1968
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 3	DATE:	01/20/2026
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Licensee Representative - Josephine Miranda		TIME COMPLETED:	02:46 PM

ALLEGATION(S):

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Licensee does not ensure that resident's dietary needs are met.
Licensee does not assist resident with bathing.

INVESTIGATION FINDINGS:

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On 01/20/2026 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to provide determinations on the above mentioned allegations. Upon arrival, LPA was greeted by staff and was granted access. LPA met with Licensee Representative, Josephine Miranda and LPA explained the purpose of the visit.

To investigate the allegations, LPA conducted an initial unannounced complaint visit on 05/07/2025. From 9:50 a.m. to 11:00 a.m., LPA completed a physical plant inspection. During the facility tour, LPA interviewed two (2) hospice agency staff who were assisting a resident, as well as three (3) of the five (5) residents present. Resident #2 (R2) was sleeping, and Resident #5 (R5) did not respond to LPA’s questions. LPA also interviewed a wound care agency staff member who was assisting a resident. From 11:00 a.m. to 12:00 p.m., LPA reviewed five (5) resident records and three (3) staff records and obtained copies not limited to the following: residents’ physician’s report, pre-admission appraisals, resident appraisals and admission agreements. LPA also obtained copies of Personnel Records and the meal menu the facility uses.
(Continue to LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2026

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 3

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.	FACILITY NUMBER: 197607012
	VISIT DATE: 01/20/2026

NARRATIVE

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(Continued from LIC9099-C)
Allegation: Licensee does not assist resident with bathing. It is alleged that Resident #1's (R1's) feet are dirty and appear to be rotted. LPA's review of R1's Home Health paperwork revealed R1 was assessed for services and started services on 05/22/2025. Home Health assessment confirmed wounds on R1's right and left heal. LPA's review of R1's appraisal revealed R1 requires assistance with activities of daily living (ADL's) such at bathing. On 05/07/2025, LPA observed that R1’s toenails were uncut, however, the white bandages wrapped around both feet were clean, with no visible blood or soiling on the bandages or R1’s feet. LPA did not observe any visible dirt or smell foul odors. Interview with Josephine on 05/07/2025 revealed she made sure R1 received bed baths as they were waiting on more information regarding the assistance R1 would require. Furthermore, Josephine stated R1 was bathed two times a week. LPA's interview with two (2) staff denied the allegation. During LPA's interview with R1, the resident stated they were bathed. LPA's interviews with R3 and R4 did not corroborate the allegation. Based on interviews and observations, there was insufficient evidence to the allegation, Licensee does not assist resident with bathing. Therefore, the allegation is deemed Unsubstantiated at this time.

LPA conducted a physical plant tour of the facility. No immediate health or safety hazards observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 3

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JBM RESIDENCE HOME, INC.	FACILITY NUMBER: 197607012
	VISIT DATE: 01/20/2026

NARRATIVE

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(Continued from LIC9099)

LPA additionally interviewed two (2) residents’ family members who were visiting the facility. LPA conducted subsequent visits. On 05/09/2025, LPA interviewed Staff #1 (S1) and observed Josephine checking on Resident #4 (R4). At approximately 10:00 a.m., S1 began preparing breakfast for the residents. LPA obtained copies of Home Health and/or Hospice records for Resident #1(R1), Resident #2 (R2) and resident #5 (R5). On 08/11/2025, During this visit, LPA interviewed Josephine, two (2) of four (4) residents present, and a family member visiting a resident. LPA reviewed resident records and obtained copies of relevant information. On 08/20/2025, from approximately 11:20 a.m. to 12:00 p.m., LPA Rios conducted a physical plant tour and interviewed the Josephine and Staff #2 (S2). From approximately 12:00 p.m. to 12:42 p.m., LPA observed S2 cooking and preparing lunch for the residents. From 12:42 p.m. to 1:22 p.m., LPA interviewed one (1) of the three residents residing in the facility and a family member visiting Resident #4 (R4). LPA also observed three (3) out of three (3) residents eating their meals.

Allegation: Licensee does not ensure that resident's dietary needs are met. It is alleged that Resident#1 (R1) is missing meals and appears to be extremely hungry and thirsty. During interviews with R1 on 05/07/2025 and 08/11/2025, the resident spoke generally about their experience at the facility but did not provide information regarding the allegation. LPA's interviews with R3 and R4 did not corroborate the allegation. LPA's interview with R4's family member on 08/20/2025, revealed they visit R4 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 R4's family member the meals are served on time, look good and R4 eats well. LPA's interview with two (2) staff and Josephine deny the allegation. LPA's Interview with three (3) representative from outside agencies providing care to residents in the facility did not corroborate the allegation. LPA interview with one (1) of R1’s family members, on 05/07/2025 and 08/11/2025 stated that R1 is eating the meals prepared by the facility. The family member reported that the food appears fine overall, but suggested that it be made softer for R1. LPA's interview with one other family member for R1 revealed R1 is hungry and thirsty every time they visit. Due to inconsistent and insufficient evidence LPA could not corroborate the allegation. Therefore, based on interviews and observations, this allegation is deemed Unsubstantiated at this time.

Page 2 of 3 (Continue to LIC9099-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2026

LIC9099 (FAS) - (06/04)

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