Fire safety and emergency preparedness
Cited in 3 reports, with 7 deficiencies in total.
JCP COTTAGE
14241 LA MIRADA ST, Victorville CA 92392
6 bedsLatest official report Nov 7, 2025Licensed
Additional info
- Telephone
- (760) 780-0970
- Licensee
- JCP SENIOR CARE LLC
- Administrator
- FRISCO SANRY
- Contact
- FRISCO SANRY
- License first date
- Dec 20, 2018
- License effective date
- Dec 20, 2018
- District office
- SAN BERNARDINO ASC · (951) 248-2222
- Regional office
- 56
- Clients served
- 935 - ELDERLY
Summary
The available records show 3 Type A and 17 Type B deficiencies for this facility.
- Most recent inspection
- Nov 7, 2025
- Most recent deficiency
- Nov 7, 2025
No later report is available, so the records do not show what happened afterward.
What Type A and Type B mean
- Type A
- 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
- Violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care.
Both classifications are published by California CDSS and are shown as published. SeniorLivingFacts does not rename them or add a severity level of its own.
At a glance
Counts cover the five-year public record. Typical figures are the median for the 229 San Bernardino County facilities licensed for 6 or fewer beds.
In the available public five-year record, CCLD published 6 reports for this facility: 4 inspections, 2 complaint investigations, and 0 licensing or administrative records.
Those records contain 3 Type A and 17 Type B deficiencies.
0 deficiencies have explicit official correction or clearance evidence in the loaded records.
- Official inspections
- 4
- Recorded deficiencies
- 20
- Type A deficiencies
- 3
- Type B deficiencies
- 17
- Substantiated complaints
- 0
- Repeated topics
- 3
About the same as most this size
1 in the last 12 months
Well above the typical 1
7 in the last 12 months
Most this size have none
1 in the last 12 months
Well above the typical 1
6 in the last 12 months
Most this size also have none
0 in the last 12 months
Last 36 months
Repeated topics
Topics cited in more than one report during the last 36 months. A repeat may show a pattern worth asking about. Each date opens its report below.
Health conditions and treatments
Cited in 3 reports, with 3 deficiencies in total.
Licensing and administration
Cited in 2 reports, with 2 deficiencies in total.
Official report history
All preserved reports from the most recent to the oldest, sortable by report type.
Inspection
Fire safety and emergency preparednessType A
- Official classification
- Type A
- Official code
- 87202(a)(2)
- Regulation authority
- CCR
What the official deficiency says
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. 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 approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by placing a bedridden resident in a nonambulatory bedroom which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/08/2025 Plan of Correction Licensee stated that she will transfer the bedridden resident into the bedridden approved bedroom and will send pictures of both rooms after transfer to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87470(c)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above by not reviewing/updating the infection control plan annually which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/14/2025 Plan of Correction Licensee stated that she will review/update the infection control plan and send proof to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not having a staff present with a current and active CPR certification upon LPA's arrival which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/11/2025 Plan of Correction Administrator stated that the staff will renew their CPR certification and send proof to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Medical and dental careType B
- Official classification
- Type B
- Official code
- 87465(a)(4)
- Regulation authority
- CCR
What the official deficiency says
(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not assisting the residents with their medication as prescribed by their physician which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/14/2025 Plan of Correction Administrator stated that she will train staff on the process of administering medication and send proof to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(a)(2)
- Regulation authority
- HSC
What the official deficiency says
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not having emergency kits which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/14/2025 Plan of Correction Licensee stated that she will purchase or assemble emergency kits and send proof to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not keeping proof of the previous of the drills conducted prior to October 2025 which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/11/2025 Plan of Correction Licensee stated that she will review the regulation cited and submit a statement of understanding to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(d)
- Regulation authority
- HSC
What the official deficiency says
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not reviewing/updating the emergency disaster plan annually which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/14/2025 Plan of Correction Licensee stated that she will review/update the emergency disaster plan with the current version and send proof to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Inspection
Hazardous items and storageType A
- Official classification
- Type A
- Official code
- 87309(a)
- Regulation authority
- CCR
What the official deficiency says
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in making the cleaning product in the master bathroom and magnetic key on the kitchen cabinet accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/05/2024 Plan of Correction Licensee made the magnetic key and cleaning product inaccessible. Licensee stated that she will train staff on regulation cited and submit proof of attendance sheet to LPA via email by 11/19/24.
Plan of correction recorded
Correction not verified in available records
Background checksType A
- Official classification
- Type A
- Official code
- 87355(e)
- Regulation authority
- CCR
What the official deficiency says
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing a staff assist a resident without background clearance which poses an immediate health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/05/2024 Plan of Correction Licensee stated that the staff without background clearance will not be volunteering in the facility as of today. Licensee will submit a statement of understanding on regulation cited by 11/12/24 via email to LPA.
Plan of correction recorded
Correction not verified in available records
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87470(c)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, record review, the licensee did not comply with the section cited above by not having an Infection Control Plan available which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/12/2024 Plan of Correction Licensee stated that she will download, complete and submit the Infection Control Plan to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.605
- Regulation authority
- HSC
What the official deficiency says
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, 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, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by providing proof of an active liability insurance which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/12/2024 Plan of Correction Licensee stated that she will submit proof of an active liability insurance to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(a)
- Regulation authority
- CCR
What the official deficiency says
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by maintaining a broken mirror on the hallway bathroom, dirty bathtub and sink in the bathroom of the master bedroom and a broken side gate door on the left side of the backyard in the facility which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/19/2024 Plan of Correction Licensee stated that she will repair the broken mirror on the hallway bathroom and side gate door on the left side of the backyard, and clean the dirty bathtub and sink in the bathroom of the master bedroom. Licensee will submit pictures and video as proof to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87303(e)(5)
- Regulation authority
- CCR
What the official deficiency says
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by maintaining a non-skid mat in the master bathroom bathtub which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/12/2024 Plan of Correction Licensee stated that she will purchase a non-skid mat and place it in the master bedroom bathtub and submit picture of item and receipt to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Facility condition and maintenanceType B
- Official classification
- Type B
- Official code
- 87307(c)
- Regulation authority
- CCR
What the official deficiency says
(c) Individual privacy shall be provided in all toilet, bath and shower areas. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above by not providing privacy to resident when they were using the bathroom by having staff leave the door open which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/19/2024 Plan of Correction Licensee stated that she will train staff on regulation cited and submit proof of attendance sheet to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Staffing, personnel, and trainingType B
- Official classification
- Type B
- Official code
- 87412(a)(11)
- Regulation authority
- CCR
What the official deficiency says
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing proof of a physical test on the health screening of a staff which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/19/2024 Plan of Correction Licensee stated that she will have staff see a physician to complete a physical test and submit proof to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above by not providing proof of emergency drills conducted quarterly which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/19/2024 Plan of Correction Licensee stated that she will train staff on regulation cited and submit proof of attendance sheet to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(d)
- Regulation authority
- HSC
What the official deficiency says
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above by not reviewing/updating the Emergency Disaster Plan annually which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/12/2024 Plan of Correction Licensee stated that she will download, complete and submit a copy of the Emergency Disaster Plan to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Inspection
Health conditions and treatmentsType B
- Official classification
- Type B
- Official code
- 87470(c)(1)(D)
- Regulation authority
- CCR
What the official deficiency says
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208. (1) The Infection Control Plan shall include all of the following: (D) The licensee shall review the use of infection control procedures in the facility at least annually, if local government public health determines an epidemic outbreak has occurred, or if the review is requested by the local licensing agency. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the administrator did not comply with the section cited above in updating the infection control plan which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/21/2023 Plan of Correction Administrator stated that he will update the infection control plan and submit a copy to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Records and plan of operationType B
- Official classification
- Type B
- Official code
- 87506(b)
- Regulation authority
- CCR
What the official deficiency says
(b) Each resident's record shall contain at least the following information: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the administrator did not comply with the section cited above in maintaining complete resident records which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/21/2023 Plan of Correction Administrator stated that he will complete and submit a copy of the forms with issues on the resident records to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the administrator did not comply with the section cited above in maintaining a log for the emergency drills performed which poses a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 11/21/2023 Plan of Correction Administrator stated that he will create an emergency disaster drill log and submit proof to LPA via email by POC due date.
Plan of correction recorded
Correction not verified in available records
Inspection
No deficiencies recorded in this report
Complaint
Allegations0 substantiated · 4 unsubstantiated · 0 unfounded
No deficiencies recorded in this reportComplaint
No deficiencies recorded in this report
Source and limits
California Department of Social Services, Community Care Licensing Division. Public facility history is described by the source as a five-year window. Older records and previous-licensee history may require a regional-office request. Type 741 RCFE-CCRCs, nursing homes, and other care settings are excluded from this page.
Read the data methodology