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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 08/11/2025
Date Signed: 08/11/2025 05:49:01 PM

Document Has Been Signed on 08/11/2025 05:49 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: 4DATE:
08/11/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Josaphine B MirandaTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Case Management - Deficiencies visit to this facility in conjunction with a complaint control #31-AS-20250429144827. LPA met with the Licensee and explained the reason for the visit. LPA may also be citing citations that have not been corrected by Licensee and those citations LPA failed to conduct a follow-up visit, within 10 business days after the POC due date.

    Previously cited on case management visit 05/07/2025.
  • While conducting the physical plant tour today LPA observed "full" bed rails on resident #1's (R1's) bed. LPA observed the bed rails extended the entire length of the bed.

  • Review of R1's and resident #2 (R2's) Physician's Reports revealed their ambulatory status as bedridden. Review of the facility sketch revealed only bedroom #3 can retain a bedridden resident. R2 is in bedroom labeled #3 according to the facility sketch. R1 in not in a bedroom cleared for bedridden. According to the Licensee R1 is able to be placed on a wheel chair with the use of a hoyer lift. According to Licensee the bedridden status is temporary and they are working with physical therapy to change status. According to R1's physician's report (LIC602A) the status is expected to persist 365 days or maybe permanent. According to the licensee they believe the LIC602A for R1 is incorrect and will request R1's family to get an update and accurate physician's report.

                                  (Continue to LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2025
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 7
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 08/11/2025
NARRATIVE
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(Continued from LIC809)
Previously cited on annual visit 05/21/2025.
  • At 3:04 p.m., licensee revealed they have not completed Medication records for centrally stored medications had still not been updated and did not accurately reflect the medication stored for four (04) out of four (04) residents.
  • Licensee stated they were unable to renew the facilities lability insurance and are still currently working on it.

  • On today's visit LPA reviewed Home Health Certification and Plan of Care for resident #1 (R1). Records revealed R1 has a prohibited health condition. LPA's interview with wound care agency staff revealed R1 has an unstageable wound on left heel. LPA requested more information regrading wound care.
  • During the investigation LPA asked Licensee on 05/07/2025 and 05/09/2025 how many Hospice residents the facility had. The licensee provided the same information on both days stating only resident R#3 was receiving Hospice service for a terminal illness Licensee went on to say R2 was previously on Hospice but was discharged prior to R3 admittance tot the facility. Licensee proceeded to provide LPA with R2's Hospice file from the previous year. LPA was able to confirm with R2's hospice agency on 5/15/2025, that resident #2 (R2) was receiving Hospice services. R2 and R3 were both on Hospice since R3's admittance on 3/31/2025 until R3's passing on 05/09/2025.


LPA provided regulations for exception requests, and Hospice waiver. LPA reiterated to Licensee that they currently only have a hospice waiver for one resident.

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

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 08/11/2025 05:49 PM - It Cannot Be Edited


Created By: Evelin Rios On 08/11/2025 at 04:21 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: 08/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2025
Section Cited
CCR
87608(a)(5)(B)

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(a) ...Postural supports may be used under the following conditions. (5)... (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care...This requirement is not met as evidenced by:
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Licensee will remove bed rails that extend the entire length of the bed for R1 send a picture to LPA by POC due date . Half bed rails may be obtained if a written order from a physician indicating the need for the postural support shall be maintained in the resident’s record.
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Licensee did not comply with the section cited above by utilizing full bed rails for R1 who does not receive hospice care services which poses an immediate health, safety personal rights risk .
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Type A
08/11/2025
Section Cited
CCR87202(a)(2)

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(a) All facilities shall maintain a fire clearance...Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance...(2)Bedridden persons. This requirement is not met as evidenced by:
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The Licensee will ensure that the facility is in compliance with the fire clearance approved by the city or county fire department at all times. The Licensee will submit a written plan of action that will be implemented to ensure that the facility comes back into compliance and Licensee will submit
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Based on record review the licensee did not comply with the section cited above in that the facility has fire clearance for one bedridden resident and the facility currently has two bedridden residents which poses an immediate health, safety or personal rights risk to persons in care.
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an LIC200 and updated facility sketch to obtain a bedridden fire clearance if they decide to retain a second bedridden resident.
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
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2025


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 08/11/2025 05:49 PM - It Cannot Be Edited


Created By: Evelin Rios On 08/11/2025 at 04:36 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: 08/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2025
Section Cited
CCR
87615(a)(1)

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(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:
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Licensee agreed to submit an exception letter to CCLD to retain resident with a prohibited health condition. Licensee will request Wound Care Plan from wound care agency and facilities own care plan (LIC622) submit it to LPA by POC due date.
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Based on record review and interviews the licensee did not comply with the section cited above by retaining R1 who is not receiving hospice services and has a unstageable wound which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
08/29/2025
Section Cited
HSC1569.605

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...all residential care facilities for the elderly,... shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, ...
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Licensee will obtain liability insurance and send a copy of certification to LPA by POC due date.
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This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in not maintaining liability insurance which poses a 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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2025


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 08/11/2025 05:49 PM - It Cannot Be Edited


Created By: Evelin Rios On 08/11/2025 at 04:45 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: 08/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2025
Section Cited
CCR
87632(a)

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(a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department... and any future residents who may request acceptance, ... This requirement is not met as evidenced by:
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Currently facility is back to serving only one(01) resident with Hospice services. The Licensee will ensure that the facility is in compliance with their hospice waiver at all times. The Licensee will submit a written statement of understanding about their current Hospice waiver and Licensee will submit statement to LPA by POC due date.
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Based on record review and interviews the licensee did not comply with the section cited above in accepting a second resident receiving hospice services when the facility has a hospice waiver for only one resident which posed an immediate health, safety or personal rights risk to persons in care.
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Type B
08/29/2025
Section Cited
CCR87207

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No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
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The Licensee will submit a written statement of understanding about the cited regulation and submit statement to LPA by POC due date.
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Based on interviews the licensee did not comply with the section cited above in false or misleading statements on two different days regarding the same question about the number of residents receiving Hospice services in the facility which posed 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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2025


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 08/11/2025 05:49 PM - It Cannot Be Edited


Created By: Evelin Rios On 08/11/2025 at 05:19 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: 08/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/29/2025
Section Cited
CCR
87465(h)(6)

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(h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained... This requirement is not met as evidenced by:
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The Licensee has agreed to updated Centrally Stored Medication and Destruction Records (LIC622) for each resident as per facility program. Copy of LIC 622 will be sent to LPA by POC due date.
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Based on observation and record review, the licensee did not comply with the section cited above in four (04) out of four (04) residents' centrally stored medication not being properly recorded which poses a 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.
Eva Miller
NAME OF LICENSING PROGRAM MANAGER:
Evelin Rios
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2025


LIC809 (FAS) - (06/04)
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