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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601304
Report Date: 09/08/2025
Date Signed: 09/08/2025 10:48:51 AM

Unsubstantiated


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
08/29/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250829113624
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:
09/08/2025
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Shawn Bailey - AdministratorTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Licensee did not ensure staff obtained a criminal record clearance prior to working.
Licensee did not address a bed bug infestation in a timely manner.
Licensee did not ensure residents received assistance with contracted care services.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Administrator Shawn Bailey and explained the reason for the visit.

The investigation consisted of the following:
On 9/2/25 LPA conducted initial 10-day visit and toured facility, inspected living room furniture and each clients bed (total of 4) for bedbugs, LPA interviewed a total of 3 staff (S1-S4) and 2 clients (C1-C2). LPA requested the following documents to be emailed to LPA: proof of criminal clearance for S2, Invoice from Pest Control Services with details of service, Charting Notes and Contract for the 2 clients that receive nurse services and Ratio agreement with Regional Center.
On 9/3/25 LPA received and reviewed the requested documents.
During todays visit 9/8/25 LPA typed report and delivered findings on the above allegations
(Continued on LIC9099-C Page)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
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 6
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
08/29/2025 and conducted by Evaluator Tena Herrera
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250829113624

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:
09/08/2025
UNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Shawn Bailey - AdministratorTIME COMPLETED:
10:55 AM
ALLEGATION(S):
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Licensee did not maintain staffing ratios as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced complaint investigation visit regarding the above allegations. LPA met with Administrator Shawn Bailey and explained the reason for the visit.

The investigation consisted of the following:
On 9/2/25 LPA conducted initial 10-day visit and toured facility, inspected living room furniture and each clients bed (total of 4) for bedbugs, LPA interviewed a total of 3 staff (S1-S4) and 2 clients (C1-C2). LPA requested the following documents to be emailed to LPA: proof of criminal clearance for S2, Invoice from Pest Control Services with details of service, Charting Notes and Contract for the 2 clients that receive nurse services and Ratio agreement with Regional Center.
On 9/3/25 LPA received and reviewed the requested documents.
During todays visit 9/8/25 LPA typed report and delivered findings on the above allegation.
(Continued on LIC9099-C Page)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20250829113624
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: 09/08/2025
NARRATIVE
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Allegation: Licensee did not maintain staffing ratios as required.
It is alleged that the facility is short staffed and do not maintain the required ratio. LPA interviewed 3 staff and 2 out of 3 staff denied the above allegation and stated that during their shift there is always at least 2 caregivers. Interview with S1 revealed that on 8/18/25 a staff assisted one of the clients on an outing leaving 3 clients behind with 1 caregiver, the required ratio for facility through Regional Center is 1:2 or 1:1, regional center had an unannounced visit during this day and also addressed this concern. LPA reviewed the facility consultation/corrective action written report dated 8/29/25 through South Central Los Angeles Regional Center where the information provided during interview with S1 was documented. This allegation is substantiated and details will be documented on the LIC 9099-D page.

Based on LPAs observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 6 are being cited on the attached LIC 9099D. Exit interview held, and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20250829113624
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: 09/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2025
Section Cited
CCR
85065.5(a)(1)
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85065.5 Day Staff-Client Ratio (a) Whenever a client who relies upon others to perform all activities of daily living is present, the following minimum staffing requirements shall be met: (1) For Regional Center clients, staffing shall be maintained as specified by the Regional Center but no less than one direct care staff to three such clients. This requirement was not met as evidence by:

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Licensee/Administrator to review the rquirement under Title 22 and upon reading/understanding the requirement they are to fill out and sign the LIC9098 form that was provided durimg todays visit. This must be emailed to LPA by POC due date.
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Based on record review, and interview with S1, the licensee did not comply with the section cited above as it was revealed that on 8/18/25 facility was providing care and supervison without being on ratio as there was 1 staff for 3 clients, the required ratio for facility is 1:2 or 1:1, 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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20250829113624
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: 09/08/2025
NARRATIVE
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Allegation: Licensee did not ensure staff obtained a criminal record clearance prior to working.
It is alleged that staff S2 has been working in the facility since 08/06/2025 without being cleared to work. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation stating that they have gone through the fingerprint/criminal record clearance prior to hire. Interview with S1 revealed that S2 is criminally cleared and associated with a sister facility, however, they are not associated to Bailey Care Homes 4. LPA reviewed the association list for facility and did not observe S2 on the list, additionally LPA accessed Guardian and observed S2 on the website but not associated to Bailey Care Homes 4. Interviews with S1 and S3 revealed that S2 does sometimes work at facility for coverage. Prior to LPA leaving during initial visit dated 9/2/25 Administrator/Licensee provided proof of S2 being associated to facility with association date of 9/2/25. This allegation is unsubstantiated, however, LPA will issue citation for staff not having proper criminal transfer to facility prior to working.

Allegation: Licensee did not address a bed bug infestation in a timely manner. It is alleged that there have been bed bugs in the living room and bedrooms of the facility since 06/17/2025 and the facility just had a treatment service done in early August 2025. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation. Interview with S3 revealed that although they have felt itchy within the facility, the Administrator did address the concern right away and had a pest control service inspect facility. LPA inspected 4 client bedrooms and their linens, mattresses and furniture and did not observe any bed bugs or insects. LPA interviewed 2 clients and both clients denied the above allegation. LPA spoke with S1 and it was revealed that there is a pest control service for the facility as this was mentioned and S1 took preventative action. LPA reviewed invoices with pest control service and it was revealed that on 8/14/25 carpet beetle larva was found in 2 bedrooms and treatment was provided in area and the living room was also treated for bed bugs. This allegation is unsubstantiated, however, LPA will issue citation for the facility not being free of bugs/insects.

Allegation: Licensee did not ensure residents received assistance with contracted care services. It is alleged that C1 is not receiving their contracted nursing services. LPA interviewed 3 staff and 3 out of 3 staff denied the above allegation. S1 stated the although C1 does often refuse assistance and care, there is a nurse who provides C1 with services 2-3 times weekly. Interviews with S3 and S4 also stated they have seen the nurse a few times during the week in the facility assisting R1. LPA interviewed C1 and C1 denied that above allegation and stated a nurse does visit and provide care and assistance regularly. LPA reviewed the nurse charting notes from June-August 2025 and they revealed that C1 is provided with services 2-3 times weekly. This allegation is unsubstantiated. (Continued on LIC 9099-C page)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 28-AS-20250829113624
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: 09/08/2025
NARRATIVE
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Based on statements and interviews conducted with staff/clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
Exit interview held, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6