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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601304
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:24:19 PM

Document Has Been Signed on 09/08/2023 03:24 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
GREATER LA AC/SC, 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:
09/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:52 AM
MET WITH:Shawn Bailey - LicenseeTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA was screened and met by Jamila Neal, Direct Service Professional II (DSP II) and Reginald Roy, Direct Service Professional II (DSP II) and explained the purpose of the visit. LPA spoke with the Executive Director, Tamara Frisby on the phone and had advised LPA that someone will be at the facility to access files. At 12:18pm, Asst. Administrator Kendall D. Edwards arrived and assisted LPA with the inspection. Shortly after, Shawn Bailey, Licensee arrived. The facility is licensed to serve for (4) Developmentally Disabled Adults, ages 18 through 59, (3) clients may be non ambulatory. There was one (1) client present at the facility during the visit, and the other three (3) clients were at the Day Program. All clients residing at this facility receive case management services provided by South Central LA Regional Center.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a visitor sign-in station and PPE supplies located near the front door. The facility has not submitted the required Infection Control Plan. Facility has COVID-19 signage posted throughout the facility. Bathrooms have hand washing signs, soap and paper towels. Staff are adhering to infection control requirements.

Physical Plant/Environment Safety: The facility is a single storey home located in a residential neighborhood, contains a total of four (4) client bedrooms, two (2) full bathrooms, half (1/2) bathroom, a living room/activity area, kitchen, dining area, backyard, and attached garage. Currently, there are four (4) clients living in the facility. According to the Licensee, the facility is considered a Community Placement Project (CPP). The interior and exterior physical plant was inspected. Client bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, chair and sufficient closet space. Bathrooms have non-skid materials and contained hygiene supplies including liquid soap, paper towels, and toilet paper. Exit doors are free of any obstruction and there are no pools or large bodies of water. Backyard was inspected and there was a sitting area, but did not have a shaded area as the patio umbrella was broken. LPA observed torn window screen on bathroom #3. Attached garage was inspected and there is an extra refrigerator/freezer to stock up additional food items. Kitchen knives, sharps objects, cleaning supplies and toxic substances are locked and inaccessible to clients. LPA observed that the cleaning supplies were stored and mixed with the food supplies in the attached garage. There is a fire extinguisher observed to be fully charged and was last serviced on July 12, 2023. Smoke alarms and carbon monoxide were operable. There are no firearms or weapons stored at the facility. Water temperature readings are not within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 121.6 deg F in bathroom #1, 127.7 in bathroom #2, and 125.7 in bathroom #3.

Operational Requirements: A current Plan of Operation was reviewed. The Infection Control Plan has not been added to the Plan. A fire clearance for (4) clients is in place. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in general aggregate is valid and will expire on 2/28/2024. Surety Bond is in effect and in force with bond amount of $5000. Last Fire Drill was conducted on 8/18/2023.

*****REPORT CONTINUED ON LIC809-C*****

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/08/2023
NARRATIVE
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Staffing: A total of ten (10) staff members including the Assistant Administrator provide care and supervision to the clients. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and associated to the facility.

Personnel Records/Staff Training: Reviewed files for three (3) staff. Proof of staff training, health clearance, vaccinations and 1st Aid/CPR training are current. Assistant Administrator certificate is valid and expiring on 08/14/2024. Assistant Administrator stated that he has a valid HIV/AIDS training but did not have the proof at the time of visit. He will send a copy to LPA by email.

Client Rights-Information: Client personal rights are posted. Per Assistant Administrator, facility provides internet services to all clients and have access to the facility phone. Asst. Administrator also stated two (2) of the clients have a personal cell phone and (1) out of (4) clients has her own tablet. LPA attempted to conduct client interviews but (1) was sleeping and (3) were in the Day Program..

Client Records-Incident Reports: LPA reviewed two (2) client files. Client files are maintained at the facility. Physician's Report (including TB and Ambulatory Status), Consent For Medical Treatment, Individual Program Plan (IPP), Behavioral Reports, Client Cash Resources, Special Incident Reports, Client Personal Property and Clients Personal Rights observed.

Food Service: There are sufficient food supplies of 2-day perishable and 7-day non-perishable items. The food is properly stored in the refrigerator. There are no clients with special diets residing at this facility. Kitchen is kept clean and free from rodents and other vermin. Plates, cups and utensils are kept cleaned and stored properly.

Health Related Services: The medications are centrally stored and in their original containers. Medications were reviewed for two (2) clients to confirm medication is given as prescribed and is documented properly. The facility uses the Medication Administration Record (MAR) log to document medications given. Medications are administered as prescribed by the Physician. Medications are bubbled packed.

Incidental Medical Services: Per the Administrator, there are no clients at this home with incidental medical services nor have a restricted health condition.

Disaster Preparedness: The facility has a complete Emergency Disaster and Mass Casualty Plan.

Emergency Intervention: Not-Applicable.

Deficiencies cited on LIC 809D. Exit interview, appeals rights and a copy of this report was provided to the Licensee, Shawn Bailey.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 09/08/2023 03:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/08/2023 at 02:20 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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 in which the water temperature readings are not within the required 105 - 120 degrees Fahrenheit. Hot water supply measured 121.6 deg F in bathroom #1, 127.7 in bathroom #2, and 125.7 in bathroom #3 which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 09/11/2023
Plan of Correction
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The licensee will ensure that the hot water temperature shall not be less than 105 degrees F and not more than 120 degrees F. The licensee will send plan of correction and submit 7 consecutive days of hot water log (starting 9/08/23 until 9/15/23) to LPA/CCL by POC due date.
Type A
Section Cited
CCR
80076(a)(16)
Food Service
(a) In facilities providing meals to clients, the following shall apply: (16) Soaps, detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies.

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 in which the cleaning supplies, disinfectants were stored and mixed with food supplies in the attached garage which poses an immediate health, safety or personal rights risk to clients in care.
POC Due Date: 09/11/2023
Plan of Correction
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Licensee will ensure that the cleaning supplies, chemicals, disinfectants are secured and stored separately from the food supplies. Licensee will submit photos showing the separate storages for the items mentioned above to CCL/LPA 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/08/2023 03:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/08/2023 at 02:20 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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 85022. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in which the licensee did not submit the Infection Control Plan to CCL as required which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 09/22/2023
Plan of Correction
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Licensee agreed to develop and submit a copy of the Infection Control Plan to CCL/LPA by POC due date.
Type B
Section Cited
CCR
80087(a)
Building 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 evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in which LPA observed the discarded mattress, broken chest drawers, chairs, and patio umbrella in the backyard and side yard which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 09/22/2023
Plan of Correction
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Licensee will submit photos of the cleaned and cleared out side and backyards to CCL/ LPA on or before the 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 09/08/2023 03:24 PM - It Cannot Be Edited


Created By: Bennette Pena On 09/08/2023 at 02:20 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: 09/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(b)
Fixtures, Furniture, Equipment, and Supplies
(b) All window screens shall be in good repair and be free of insects, dirt and other debris.

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 in that LPA observed torn window screen on bathroom #3 which poses/posed a potential health, safety or personal rights risk to clients in care.
POC Due Date: 09/22/2023
Plan of Correction
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Licensee shall ensure resident window screens are in good repair. Licensee shall submit picture proof of correction, and self-certification of correction to LPA/CCL 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:David Sicairos
LICENSING EVALUATOR NAME:Bennette Pena
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
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