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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607012
Report Date: 09/05/2025
Date Signed: 09/05/2025 12:02:35 PM

Document Has Been Signed on 09/05/2025 12:02 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:		DIVINA L. HEIDELBERGFACILITY TYPE:
740
ADDRESS:3205 ARIOUS WAYTELEPHONE:
(661) 522-1968
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 6CENSUS: 3DATE:
09/05/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Josephine Miranda / LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Evelin Rios conducted a Plan of Correction (POC) Visit. LPA Rios met with Licensee Josephine Miranda. Entrance interview was conducted. Purpose of the visit was explained.

LPA conducted a physical plant tour of the facility. LPA reviewed POCs that have not been completed. LPA provided Licensee a Non-Compliance Conference letter requesting the Licensee and Administrator to attend a meeting in the Woodland Hills South Regional Office (RO)

The following deficiency were not corrected:

Health and Safety Code 1569.605: Licensee did not maintain liability insurance. POC has not been cleared as of POC due date 08/29/2025.

87615(a)(1) Prohibited Health Conditions: Licensee retained R1 who is not receiving hospice services and has a Stage 4 pressure injury. Licensee agreed to submit an exception letter to CCLD to retain resident with a prohibited health condition. Licensee failed to provide exception letter by POC due date 08/12/25.

87202(a)(2) Fire Clearance: Facility has fire clearance for one (01) bedridden resident in room #3, and based on physician's reports the facility currently has two (02) bedridden residents. POC has not been cleared as of due date 08/11/2025.

The facility removed bed rails that extend the entire length of the bed for R1 and replaced them with half bed rails. Although a bed rail that extends from the head half the length of the bed and used only for assistance with mobility is allowed the facility has not obtained a written order from a physician indicating the need for the postural support.

Exit interview conducted. Deficiency cited (refer to LIC809-D). Civil Penalty Assessed for failure to correct (refer to LIC421FC). Appeals rights provided. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/05/2025
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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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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Document Has Been Signed on 09/05/2025 12:02 PM - It Cannot Be Edited


Created By: Evelin Rios On 09/05/2025 at 11:19 AM
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: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2025
Section Cited
HSC
1569.605

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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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Type A
09/06/2025
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
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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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LIC200 with updated facility sketch to obtain additional bedridden fire clearance.
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: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/05/2025 12:02 PM - It Cannot Be Edited


Created By: Evelin Rios On 09/05/2025 at 11:28 AM
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: 09/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2025
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 and required documentation to CCLD to retain resident with a prohibited health condition 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 A
09/09/2025
Section Cited
CCR87608(a)(3)

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(a) Based on the individual's ... appraisal... Postural supports may be used under the following conditions. (3)A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met as evidenced by:
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Licensee agreed to obtain a written order from a physician indicating the need for the bed rail. A copy of the order will be provided to LPA by POC due date.
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Licensee did not comply with the section cited above by not obtaining a written order from a physician indicating the need for bed rail that extends from the head half the length of the bed which poses an immediate health, safety personal rights risk.
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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: 09/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/05/2025


LIC809 (FAS) - (06/04)
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