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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601304
Report Date: 09/17/2021
Date Signed: 09/17/2021 03:38:40 PM

Document Has Been Signed on 09/17/2021 03:38 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
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:
09/17/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:12 PM
MET WITH:Aidee Gutierrez - Direct Support StaffTIME COMPLETED:
04:15 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit during a complaint investigation visit for deficiencies observed. LPA Flores met with Aidee Gutierrez and explained the reason for the visit.

LPA Flores conducted a health and safety check that consisted of the following: LPA tour 4 client bedrooms, kitchen, living room, 3 client bathrooms, and backyard. LPA observed the following: Client's bedrooms have the required bedding and furniture. Bedroom #3 has electrical output case broken, and a floor tile about 2 feet long is loose at the entrance of the room. LPA tested water temperature as follow bathroom #1 tested at 117.1 degrees F, bathroom #2 tested at 113.7 degrees F, bathroom's toilet was observed without a lid, bathroom #3 116.5 degrees F which is within the required 105 to 120 degrees F. Facility has sufficient food 2 days of perishables and 7 days of non perishables. Knives and cleaning supplies were observed locked on a cabinet above washer and dryer area. Fire sprinkle system was observed. Medication was observed in office and under lock. Fire extinguisher observed and current.

Deficiencies will be cited on 809D per Title 22 regulations. Exit interview was conducted with Aidee Gutierrez direct support staff and a copy of this report, 809D, and appeal rights was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 09/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/17/2021
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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Document Has Been Signed on 09/17/2021 03:38 PM - It Cannot Be Edited


Created By: Mary G Flores On 09/17/2021 at 03:21 PM
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
, 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: 09/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2021
Section Cited
CCR
80087(a)

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80087 Bulidings and Grounds: (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.



This requirement is not met as evidencey by:
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Licensee will replace electrical output, repair floor tile in bedroom #3, will replace toilet lid in bathroom #2 and will submit pictures to the department by 10/1/21.
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Based on observation licensee did not ensure electrical output, floor tile in bedroom #3 and toilet lid in bathroom #2 are in good repair 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.
SUPERVISOR'S NAME:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2021


LIC809 (FAS) - (06/04)
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