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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601304
Report Date: 09/26/2025
Date Signed: 09/26/2025 04:59:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/10/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250910143108
FACILITY NAME:BAILEY CARE HOME #4FACILITY NUMBER:
198601304
ADMINISTRATOR:SHAWN L. BAILEYFACILITY TYPE:
735
ADDRESS:10413 VULTEE AVE.TELEPHONE:
(562) 622-0806
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY:4CENSUS: 4DATE:
09/26/2025
UNANNOUNCEDTIME BEGAN:
02:19 PM
MET WITH:Jennifer Estrada - House LeadTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not meet a client's colostomy needs.
Staff mishandled a client's medication while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent visit regarding the above allegations. LPA met with Jennifer Estrada - House Lead and explained the reason for the visit.

The investigation consisted of the following:
On 9/19/25 LPA obtained copies of the following from Client #1's file: Nursing Consultation Log June-August 2025, Nursing Notes July 2025 and Physician Order Dated 8/5/25. LPA also obtained a copy of the Regional Center Facility Consultation/Corrective Action Written Report Dated 9/17/25, and interviewed 3 Staff and 1 Client. During todays visit LPA delivered findings on the reported allegations.

(Continued on the LIC9099-C page)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20250910143108
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BAILEY CARE HOME #4
FACILITY NUMBER: 198601304
VISIT DATE: 09/26/2025
NARRATIVE
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The investigation revealed the following:
Allegation: Staff did not meet a client's colostomy needs.
It is alleged that the nursing staff is not changing C1’s colostomy bag correctly and instead of changing it every 3-5 days it is being changed up to every 7-12 days. LPA interviewed 2 staff and interview with S2 revealed that Regional Center has previously addressed this concern and a CAP (Corrective Action Plan) was provided to ensure that moving forward C1 is having the colostomy bag replaced as prescribed. LPA Reviewed Nursing Charting Logs from July-August 2025 and it was revealed that C1's colostomy bag was changed on the following dates on the following dates: 6/13/25, 6/18/25, 6/27/25, 7/7/25, 7/18/25, 7/26/25, which is outside of the required 3-5 day timeframe for bag changes that is written on the Physician’s Orders. Although the 3 staff interviewed denied the allegation, the Nursing Charting Logs and Nursing Notes showed evidence that the colostomy bag was not being changed pre the physician’s orders. This allegation is therefore Substantiated.

Allegation: Staff mishandled a client's medication while in care.


It is alleged that C1 ran out of their medication on 7/17/25 and was transported to the hospital to get medication refilled on 7/20/25. LPA interviewed 3 staff and interview with S2 revealed that Regional Center has previously addressed this concern and recommended that there be a medication training completed with an outside agency for staff that assist with medication as there was a 4 day gap where C1 was missing a medication. LPA reviewed Nurses Notes and observed that on 7/16/25 it was discovered that C1’s medication was low, staff called to refill the medication and pharmacist stated there were no refills left and to contact PCP (Primary Care Physician), on 7/17/25 the PCP was contacted, messages were left with no return calls, ER visit to obtain medication was done on 7/20/25 and the wrong dosage was provided, C1 was able to see PCP on 7/22/25 and the correct medication was provided. LPA conducted a medication review and did not observe any issues or errors. Given that there was a 4 day gap where C1 was out of their routine medication this allegation is Substantiated.

Based on LPAs observations, interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 1 are being cited on the attached LIC9099-D. Exit interview held, and a copy of this report and appeal rights were emailed to Licensee - shawnspears70@gmail.com and Executive Director - tfrisbey@bchlaca.com.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250910143108
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BAILEY CARE HOME #4
FACILITY NUMBER: 198601304
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2025
Section Cited
CCR
80092.4(a)(5)(B)
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80092.4 Colostomy/Ileostomy (a) A licensee of an adult CCF may accept or retain a client who has a colostomy or ileostomy if all of the following conditions are met: (5) The licensee ensures that: (B) The ostomy bag and adhesive may be changed by facility staff who receive training from the licensed professional as specified in Sections 80092.1(k) through (k)(2). This requirement was not met as evidence by:
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Licensee/Administrator to review the entire regulation and complete the LIC9098 form that was provided during todays visit and send a copy to LPA by end of day 9/27/25.
Additionally Licensee/Administrator to conduct a training on Colostomy assistance to staff and submit a copy of the training log with partisipant names/ signatures to LPA ny 10/10/25.
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During file review LPA reviewed Nursing Charting Logs from July-August 2025 and it was revealed that C1’s colostomy bag was changed on the following dates 6/13/25, 6/18/25, 6/27/25, 7/7/25, 7/18/25, 7/26/25, which is outside of the required 3-5 day timeframe for bag changes that is written on the Physician’s Orders.
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Type A
09/27/2025
Section Cited
CCR
80075(b)
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80075 Health Related Services (b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. This requirement was not met as evidence by:
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*Licensee/Administrator has since refilled the medication and per LPA's medication review dated 9/19/25 LPA did not observe any issues*
Licesee/Administrator to conduct a medication training for all staff that assist with medication administration and provide LPA with a copy of the training log with participant names/ signatures (and certificates of completion) to LPA by 10/10/25.
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During file review LPA reviewed C1's Nurses Notes and observed that during 7/16/25-7/22/25 C1's was without 1 routine medication.
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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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3