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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607012
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:01:33 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
12/27/2022 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20221227154613
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
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Josephine MirandaTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident left in soiled diaper for extended amount of time.
INVESTIGATION FINDINGS:
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On 01/06/2023 at 10:08 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived to the facility to conducted a complaint visit to investigate the above mentioned allegation. Upon arrival, LPA was greeted by the Administrator Josephine Miranda. From 10:08 a.m. – 10:30 a.m. LPA conducted a physical plant inspection to assure the health a safety of the clients.

Resident left in soiled diaper for extended amount of time.
It is alleged that resident #1(R1) has been left in soiled diapers multiple times within the last 30 days. From 10:30 a.m. to 11:07 a.m. interviews were conducted with two out of four residents including the Administrator. From 11:08 a.m. to 11:30 a.m. LPA reviewed facility records and copies of facility records were obtained. From 11:30 a.m. to 12:00 p.m. LPA interviewed two credible witnesses that provide direct care to R1. Two out of two credible witnesses corroborated, R1 has been left in soiled diapers when they arrive to provide care. (Lic 9099 Continued)
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20221227154613
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: 01/06/2023
NARRATIVE
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Administrator stated there is no incontinent care plan on file for any of the residents in care. Based on the information obtained through interviews and record review 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: 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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20221227154613
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: 01/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
87625(b)(2)
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87625(b) ... the licensee shall be responsible for the following:(2)Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.
This requirement is not met as evidenced by:
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The administrator has agreed to the following:1. Update resident's Appraisal and Needs and Service plan to include the incontinent care plan. Plan shall come from an appropriate skilled professional. Submit to CCL. 2. Conduct incontinent care training for staff.
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Based on interview and record review, Administrator did not comply with the above section by failing to check R1 incontinent resident in regular intervals including during the night, which poses an immediate health, safety and personal rights risk to residents 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3