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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601304
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:07:15 PM

Document Has Been Signed on 03/27/2023 04:07 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:
03/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:House Manager Mary GeorgeTIME COMPLETED:
04:20 PM
NARRATIVE
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On 3/27/23 at 10:47 a.m., Licensing Program Analyst (LPA) Jewel Baptiste conducted an unannounced Annual/Required inspection to Bailey Care Homes #4. Upon arrival LPA was greeted by Direct Support Professional (DSP) Blanca Samayoa who contacted the Executive Director Tamara Frisby. At 11:55 a.m. House Manager Mary George arrived to assist with today's visit. At 2:00 pm Administrator Shawn Bailey joined the visit. This home is licensed to serve (4) Developmentally Disabled Ambulatory Adults, (3) non-Ambulatory and (1) Ambulatory Adults ages 18 through 59. The home is a vendor of South-Central Regional Center. There were (1) clients in care during the time of this visit, the other (2) clients were at the day program. The last emergency disaster/fire drill was conducted on 3/06/23. LPA searched administrator certificates online and noted Shawn Bailey’s name on the pending list. During today's visit LPA inspected the physical plant inside and outside, reviewed the food supply, tested the smoke/carbon monoxide detectors, reviewed (3) staff files, (3) client files, medications, and medication administration records for (3) clients and P&I.

This home contains a living room, attached garage, dining room, kitchen, 4 client bedroom, 2 bathrooms, office. and observed all (4) client bedrooms, contained required furniture, lamps, dresser, chair, and closet space. The two bathrooms contain a working toilet, basin, and water faucet, walk in shower with grab bar, shower chair, and bathmat. Bathroom # 3 has loose tiles and broken shower knob. The temperature measured at 1118.5.*F-121.6. *F (Bathroom #3) respectively which does not meet title 22 guidelines. This poses a potential safety hazard to the clients in care. The smoke detectors were battery operated and individually tested and observed to be working properly. The carbon monoxide detector was located throughout the facility, tested, and functioning properly. There were (2) fire extinguishers located in kitchen and dining room fully charged and up to date. The kitchen was toured and contained working appliances; refrigerator, stove, oven and contained dishware, cups, plates, utensils, pots, and pans with knives secured and locked. LPA observed laundry detergent, bleach and disinfectant unsecured and located on the washer and under the kitchen sink. LPA observed broken kitchen draw while touring the kitchen. The pantry was well stocked with canned goods, pasta, cereals, and the food supply contained a sufficient supply with a two-day supply of perishables and a seven-day supply of non-perishables that met title 22 guidelines. Walls and floors, cabinets and counters were clean and sanitary throughout the home
(Report continued on LIC809C.)
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE: DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2023
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 4
Document Has Been Signed on 03/27/2023 04:07 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 03/27/2023 at 03:10 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because bleach and disinfectant was observed on the washer and under the kitchen sink, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2023
Plan of Correction
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The citation was corrected during the visit. icensee will conduct staff training and ensure staff secures detergent and disinfectants by POC due date.
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above because bathroom #3 hot water was 121.6, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2023
Plan of Correction
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The facility will adjust temperature and send a temperature log for two days for bathroom#3 by POC due date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/27/2023 04:07 PM - It Cannot Be Edited


Created By: Jewel Baptiste On 03/27/2023 at 03:15 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: 03/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)

80087 (a) Buildings and Grounds:
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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, because one light in bathrrom #2 and #3 was broken. The tiles in bathroom #3 is loose, and the kitchen draw is broken, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/27/2023
Plan of Correction
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The licensee will ensure the facility will be in good repair at all times. The licensee will send photo proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lisa Hicks
LICENSING EVALUATOR NAME:Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/27/2023
NARRATIVE
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The outdoor grounds were toured and inspected.

The office contained notifications and postings: California Labor Laws, Emergency Disaster Plan, personal rights, facility license, business license, medical emergency information, let-us-know licensing contact information, consumer grievance, support services, community resources and client hygiene schedule.

The following Deficiencies were cited on the LIC809D under Title 22 California Code of Regulations Division 6, Chapter 1 & 6. Exit interview conducted with Shawn Bailey, Administrator, a copy of this report was provided, and Appeal rights given.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Jewel Baptiste
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC809 (FAS) - (06/04)
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