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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:03:29 PM


Document Has Been Signed on 01/06/2023 02:03 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



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: 4DATE:
01/06/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Josephine MirandaTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management Deficiency visit in conjunction with a complaint visit for Complaint #31-AS-20221227154613. This report is being generated to address deficiencies observed during the visit.

Upon arrival, LPA Rios conducted a physical plant tour of the facility and later a records review. LPA observed two (2) out of four (4) residents with bed rails. Resident#1 (R1) was observed to have half rails and resident #2 (R2) was observed to have full bed rails. Administrator stated R2 was not on hospice but they believed the bed rail order was on file. LPA advised Administrator, full bed rails may be ordered by a physician for resident's on Hospice. LPA and administrator did not find an order on file for R2. In addition, LPA conducted a file review of four (4) out of four (4) resident files. LPA observed three (3) (R1,R2 and R3) out of four (4) resident physician's reports/medical assessments were not done for the year 2022. Administrator stated due to Covid-19 they could not get it done. LPA advised they may have scheduled video appointments with primary care physician. Administrator stated they would work with resident’s family members to complete new physician’s reports. Administrator understood resident's with Dementia should have a Physician's report done annually or if residents condition changes.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiencies are cited (Refer to LIC 809-D). Exit Interview Conducted / Appeal Rights Discussed / A Copy of Report Issued.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/06/2023 02:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited

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Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This requirement is not met as evidenced by:
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Licensee/Administrator will 1. Remove full bed rails on R2's bed and submit a picture to LPA 2. Request a current physician order indicating the need for a bed rail by POC date.
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Based on observations made and record review, the licensee did not comply with the section cited above by utilizing full bedrails for R2 who is not on hospice which poses an immediate health, safety and personal rights risk to persons in care.
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Type B
01/27/2023
Section Cited

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(5)Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement is not met as evidenced by:
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Licensee/ Administrator will schedule medical assessments for 3 (R1, R2, R3) out of the 4 resident's in care and the most recent Medical Assessment / Physicians Report to LPA by 01/27/2023.
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Based on record reviews, the licensee did not comply with the section cited above by not ensuring a annual medical assessment for three(3) out of four(4) residents with dementia which poses a potential health, safety and 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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2