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Department of
SOCIAL SERVICES

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. MIRANDAFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 6DATE:
11/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Josephine MirandaTIME 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.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: 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


Created By: Evelin Rios On 11/19/2024 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2024
Section Cited
CCR
87411(c)(1)

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(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:
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Administrator has AGREED to submit 1st aid CPR certification to LPA by POC date.
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Based on the LPA's record review and interviews, the licensee did not comply with the section cited above in 6 staff not having active 1st aid and CPR certification which poses an potential health, safety or personal rights risk to persons in care.
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Type B
11/29/2024
Section Cited
CCR87407(e)(1)-(3)

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87407 (e)To apply for recertification after the expiration date of the certificate, but within four (4) years of the certificate expiration date, the certificate holder shall submit to the Department’s Administrator Certification Section: (1) A completed Application for Administrator Certification form LIC 9214. (2)Evidence of completion of the required continuing education hours…(3)Payment of a non-refundable delinquency fee…
This requirement is not met as evidenced by:
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Administrator has AGREED to submit a change of administrator to LPA by POC date.
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During today's inspection, the Administrator has failed to renew Administrator's certificate, or provide proof payment or training submission has been sent to Sacramento which poses an potential health, safety or 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 Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
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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