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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 05/13/2024
Date Signed: 05/13/2024 04:16:02 PM


Document Has Been Signed on 05/13/2024 04:16 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:
05/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Josephine MirandaTIME COMPLETED:
04:15 PM
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On 05/13/2024 at 2:55 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection using the CARE Inspection Tool. This is an Residential Care Facility for the Elderly (RCFE), with an approved fire clearance for a capacity five (5) non-ambulatory residents of which one (1) can be bedridden. LPA was greeted by the administrator Josephine Miranda and LPA explained the reason for the visit. An entrance interview was conducted. LPA requested a copy of the facility's Infection Control Plan as the Mitigation Plan submitted on 4/21/2021 was documented as incomplete. Administrator informed LPA they do not recall receiving information the plan was not complete. Administrator could not provide a copy.

At approximately 3:10 p.m. LPA and the administrator toured the physical plant of the facility, and the following was observed.

Kitchen/ Dinning areas: The kitchen was observed to be clean and clear of clutter. Appliances and fixtures were functioning properly. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable supply of food; properly stored. LPA observed one (1) fire extinguisher fully charged. Dining areas had appropriate table and chairs to sit the capacity of the facility. In the formal dining area LPA observed paper and boxes filling one side on the table and dining area. LPA observed, first aid kits, client medications, kept locked in a kitchen cabinet. LPA observed two (2) facility telephones, operational.
Bathrooms: The facility has three (3) total bathrooms one (1) of which is in a shared bedroom for resident use. At 3:41 p.m. LPA tested the hot water temperature in one of three resident bathrooms. The hot water temperature measured approximately 109.6*F, within regulation. LPA observed both bathrooms to be clean and properly supplied with toilet paper, hand soap, paper towels and trash bins with lids.

Bedrooms: There are a total of six (6) bedrooms, one (1) of which is designated for staff use. LPA inspected five (5) out of five (5) resident bedrooms. LPA observed each resident room to be properly furnished with beds, appropriate night stand, bedding and with sufficient lighting and storage. LPA observed extra linens in the hallway outside the bedrooms. (Continued on LIC809-C )
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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
VISIT DATE: 05/13/2024
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(Continued from LIC809)

At 3:45 p.m. LPA observed the administrator test a smoke detector that is hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly.

Due to time restraints, LPA was unable to complete the annual visit at this time. LPA did not review any staff or resident records or medication documentation at the time of this visit. A follow-up visit will be conducted at a later date to complete the annual inspection.

Exit interview conducted/Copy of report given
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2024
LIC809 (FAS) - (06/04)
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