<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601304
Report Date: 01/26/2022
Date Signed: 01/26/2022 12:31:05 PM

Document Has Been Signed on 01/26/2022 12:31 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: 3DATE:
01/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Mari Harris (Administrator)TIME COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Kruz Long conducted a Case Management visit to follow-up on the death of Client #1. LPA met with Mari Harris who assisted with the visit. LPA explained the purpose of today's visit.

Per Special Incident Report, Client #1 started to have a seizure on 01/21/22 around 5:55 pm and Staff #1 called 911. Ambulance arrived at the facility at 6:02 pm and Client #1 was taken to the hospital. At approximately 7:02 pm, the hospital called the facility and notified the facility of Client's death.

Copies of the following documents were obtained during today's Case Management visit:

-Facesheet
-Individual Program Plan
-MAR Log

Facility was unable to provide a copy of the death certificate. Administrator was informed to provide the death certificate to LPA once it becomes available.

Exit interview conducted and a copy of this report provided to Mary Harris.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1