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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601304
Report Date: 09/05/2023
Date Signed: 09/05/2023 12:44:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/10/2022 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220110111938
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:
09/05/2023
UNANNOUNCEDTIME BEGAN:
11:31 AM
MET WITH:Jamila Neal- Direct Support Professional (DSP)TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Uncleared adults working at facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced, subsequent visit at the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Direct Support Professional (DSP) Jamila Neal and explained the purpose for the visit.

On 01/19/22, LPA Tao made an initial complaint visit to the facility. During the visit, LPA Tao obtained a copy of resident roster and staff roster. LPA spoke with Administrator, Staff#2, Staff#4 and Staff #5 to confirm their names, dates of birth and dates of hired. A physical plant tour was conducted and did not observe any immediate health and safety issues.

On 9/01/22, LPA Maldonado requested a copy of the client and staff roster and interviewed Staff #1-2 (S1-S2). Staff files for S1-S5 were reviewed and the following documents were obtained: Personnel Record (LIC501), Employment Application, and New Hire Checklist.
(Report Continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
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-20220110111938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BAILEY CARE HOME #4
FACILITY NUMBER: 198601304
VISIT DATE: 09/05/2023
NARRATIVE
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The investigation revealed the following:
Regarding allegation: Uncleared adults working at facility.
It is alleged that there are staff working at the facility who are not fingerprint cleared. Per interviews conducted, (2) of (2) staff admitted to S4 and S5 having worked at the facility since hire and provided direct care and supervision to clients in care. Per staff roster provided to LPA from the Guardian site and the Facility Personnel Report Summary, it is noted that the "Association Status" for S4 and S5 is listed as "Pending". Per S1, S4 and S5 required background clearance and had yet to receive confirmation from the Caregiver Background Check branch of the licensing agency, therefore, the staff were not allowed to return until the clearance was granted. Per S1, S5 was hired around November of 2021 and S4 was hired at the end of 2021- was unable to recall exact dates. This allegation is Substantiated.

Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is SUBSTANTIATED.

Per California Code of Regulations, Title 22, deficiencies were observed and are cited on the LIC9099-D.
Additionally, Civil Penalties in the amount of $1,000 were issued during today's visit.

An exit interview was conducted with DSP, Jamila Neal, and a copy of this report and appeal rights were issued and provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220110111938
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 09/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2023
Section Cited
CCR
80019(e)(1)
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80019 Criminal Record Clearance
(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility:(1)Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement was not met as evidenced by:
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S4 and S5 stopped working prior to obtaining clearance and are no longer working at the facility. This deficiency is cleared.
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Based on interview and file review, the licensee failed to keep S4 and S5 from working and providing care to clients without proper criminal record clearance/exemption, which poses an immediate 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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3