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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 01/31/2024
Date Signed: 01/31/2024 04:28:39 PM


Document Has Been Signed on 01/31/2024 04:28 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: 5DATE:
01/31/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Josephine MirandaTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20240125095336. LPA met with the Administrator and explained the reason for the visit.
  • While conducting the physical plant tour administrator notified LPA resident #3 (R3) had passed away and that is why the room was vacant. A Death Report was not submitted to the department. According to administrator they have been busy and forgot to send it to the department.
  • While reviewing resident records, resident#2 (R2) records revealed the administrator had admitted the resident without a an written appraisal. According to administrator they are currently working on it.
  • Administrator did not have current Administrator certificate to show LPA during time of visit. Administrator will send a copy of certificate to LPA by 02/02/24.


Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report signed and delivered.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
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 01/31/2024 04:28 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: 01/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/02/2024
Section Cited
CCR
87457(c)(A)

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(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs...(A)The licensee shall be permitted to use the form LIC 603 (Rev. 6/87), Preplacement Appraisal Information, to document the appraisal.
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Administrator will complete an appraisal for R2 and submit to LPA by POC due date.
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This requirement was not met as evidenced by:
Based on interview and record review conducted with the administrator, they failed to complete an appraisal for R2 which poses a potential health, safety and personal rights risk to residents in care.
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Type B
02/02/2024
Section Cited
CCR87211(a)(1)(A)

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87211(a)(1)(A) Reporting Requirements. The licensee shall send a written report to the licensing agency and the person responsible for the resident when a resident dies, regardless of cause or where death occurred, within seven days of the death. This requirement was not met as evidenced by:
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Administrator will submit Death Report along with the death certificate for R3 to LPA by POC due date.
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Based on interview conducted with the administrator, revealed that they failed to submit a death report for R3 to CCL which poses a potential 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: 01/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2