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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601304
Report Date: 07/17/2025
Date Signed: 07/17/2025 01:53:28 PM

Document Has Been Signed on 07/17/2025 01:53 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/
DIRECTOR:		SHAWN L. BAILEYFACILITY TYPE:
735
ADDRESS:10413 VULTEE AVE.TELEPHONE:
(562) 622-0806
CITY:DOWNEYSTATE: CAZIP CODE:
90241
CAPACITY: 4CENSUS: 4DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:48 AM
MET WITH:Jennifer Estrada - House LeadTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. Upon arrival there was no one at the facility, about 20 minutes later, LPA was greeted by Jennifer Estrada who allowed entrance to the facility, and the reason for the visit was explained. The facility is licensed to serve (4) Developmentally Disabled Adults, ages 18 through 59, (3) of which may be non-ambulatory. Facility currently has 4 clients all of which are serviced by South Central Los Angeles Regional Center.

The facility is a single-story home located in a residential area in Downey, Ca. A tour of the facility includes: living room, dining area, kitchen, staff office, 4 client bedrooms, 3 client bathrooms (1 full shared bath in rooms 2-3), 1/2 bath in bedroom 1, and one full solo bath, attached garage, front yard and back yard.

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


Infection Control: The facility maintains the required Infection Control Plan.
Physical Plant & Environment Safety: LPA toured facility, clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The backyard is free of debris/hazards and the outdoor and passageways are free of obstruction. No bodies of water were observed at the facility. There are no security bars or weapons on the premises. Hygiene products are readily available for clients. All storage areas for cleaning solutions, toxins, knives, and hazardous items are kept in a locked cabinet in the garage and are inaccessible to clients. Smoke detectors and carbon monoxide detectors are operable and in compliance. There fire extinguisher was observed and is fully charged. The hot water temperature was tested in the client bathrooms was within the required range of 105-120 degrees.
(Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Tena Herrera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/17/2025
NARRATIVE
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Operational Requirements: Facility has an activity area furnished for outdoor use.
Staffing: There appears to be sufficient staffing at all times in the facility.
Personnel Records-Training: Staff files are maintained in a secure location. Administrator Stephanie Gonzalez has a valid Administrator Certificate that expires on 6/3/26. Staff #1 was missing their Health Screening a citation will be issued. All files had criminal clearance and training's documented, including valid First-Aid/CPR certificates. LPA reviewed 3 staff files during visit.
Client Rights-Information: Facility provides telephone landline/internet and maintain client rights posters and reporting posters displayed throughout the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked staff office and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan. LPA reviewed 4 client files with and Client #1 is missing their medical assessment this is a new client admitted over 30 days ago and per the requirement the medical assessment is past due, client #2 is missing their physician report that indicates clients ambulatory status, citations will be issued.
.Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Medication is properly labeled and are centrally stored in a locked cabinet within the staff office and medication are properly labeled in their original containers.
Incidental Medical & Dental: There are no clients at this home with incidental medical services nor have a restricted health condition.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites. Facility maintains documentation of the required emergency drills, with last drill conducted on 6/19/25.
Emergency Intervention: Clients at this facility do not need the use of restraints or de-escalation techniques.

Per California Code of Regulations, Title 22, and California Health and Safety Code, deficiencies observed during todays visit will be documented on the 809D.

Exit interview was held and a copy of the report and appeal rights will be emailed to Licensee and House-Lead at SHAWNSPEARS70@GMAIL.COM, ESTRADAJENNIFER31@GMAIL, TFRISBEY@BCHLACA.COM

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

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/17/2025 01:53 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/17/2025 at 01:28 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: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

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 as staff #1 is missing their health screening, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Licensee/Administator to email a copy of the Health Screening Clearance to LPA by POC due date. (per staff they have a physical scheduled for next week already)
Type B
Section Cited
CCR
80069(c)(4)
Client Medical Assessments
(c) The medical assessment shall include the following: (4) A determination of the client's ambulatory status, as defined by Section 80001(n)(2).

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 as Client # 2 does not have a physician report in file with this required information, which poses a potential health, safety or personal rights risk to persons in care. tena.herrera@dss.ca.gov
POC Due Date: 07/31/2025
Plan of Correction
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Licensee/Administator to email a copy of Client #2's physican report with current ambulatory status listed. tena.herrera@dss.ca.gov
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/17/2025 01:53 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/17/2025 at 01:28 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: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(a)
80069 Client Medical Assessment (a) Except for licensees of ARFs , prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan.

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 as Client #1 who was admitted to facility on 6/2/25 does not have the requied medical assessment within file, per staff Client has an appointment scheduled for next week, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2025
Plan of Correction
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Administrator/Licensee to provide a copy of the completed medical assessment for Client #1 via email by POC due date. tena.herrera@dss.ca.gov
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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Tena Herrera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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