197607012-11-19-2024-31-AS-ERIS-DB6VST-20241119154205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 11/19/2024
Date Signed: 11/19/2024 03:42:11 PM

Document Has Been Signed on 11/19/2024 03:42 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/ DIRECTOR:	JOSEPHINE B. MIRANDA		FACILITY TYPE:	740
ADDRESS:	3205 ARIOUS WAY		TELEPHONE:	(661) 522-1968
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	11/19/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Josephine Miranda		TIME VISIT/ INSPECTION COMPLETED:	04:00 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, Josephine Miranda and explained the reason for the visit.

1. Administrator was not able to provide LPA with a current Administrator certificate. According to administrator they have completed training and will be sending it to Sacramento to complete re-certification.

2. Review of six (6) out of six (6) staff records revealed no 1st aid or CPR on file for staff.

Deficiencies cited (refer to LIC 809D). Exit interview conducted, appeal rights and copy of report signed and delivered.

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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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Document Has Been Signed on 11/19/2024 03:42 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: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training...(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 11/29/2024
	Plan of Correction
1 2 3 4	Administrator has AGREED to submit 1st aid CPR certification to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Eva Miller	TELEPHONE: (818) 596-4373
Evelin Rios	TELEPHONE: 424-299-6104
	DATE: 11/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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