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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601304
Report Date: 07/09/2024
Date Signed: 07/09/2024 03:50:35 PM

Document Has Been Signed on 07/09/2024 03:50 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: 3DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:09 PM
MET WITH:Bria Cole - CaregiverTIME VISIT/
INSPECTION COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tena Herrera conducted the required unannounced annual inspection. LPA met with Bria Cole (Caregiver) who allowed entrance to the facility, and explained the reason for the visit, shortly after Reginald Roy (House Manager) arrived to assist with the visit. The facility is licensed to serve (4) Developmentally Disabled Adults, ages 18 through 59, (3) of which may be non-ambulatory. Facility currently has 2 Ambulatory and 1 Non-Ambulatory clients 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 bath between 2 client bedrooms, 1 bath in 1 client bedroom, 1 full bath not attached to any bedroom), 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 staff are using appropriate hand hygiene and gloves while assisting clients’ medications. Staff are cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies. The Infection Control Plan was not available for review during todays visit, LPA asked staff to send a copy to LPA via email and to have a copy of Infection Control Plan maintained at facility for future licensing visits.
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. There was a window screen missing on window in room #2 (vacant room), LPA advised staff that there must be a screen on window and to advise administrator to have one placed on window within the next week to avoid any citations. 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. (Continued on 809-C)
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE: DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2024
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
Document Has Been Signed on 07/09/2024 03:50 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/09/2024 at 02:28 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(6)(D)(2)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (6) If the client is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (D) For every prescription and nonprescription PRN medication for which the licensee provides assistance, there shall be a signed, dated written order from a physician on a prescription blank, maintained in the client's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information: (2) The exact dosage.

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 as LPA reviewed client medication and dosage for client # 1 was missed this morning (AM medication), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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Administrator/Licensee to contact physician for Client #1, advise them of the missed dosage and ask for instructions on how to proceed given the missed dosage. SIR (special incident report) to be created with all information and to be emailed to LPA by 7/10/24. Additionally a training is to be scheduled and completed no later than 7/24/24 for all staff assisting with medication administration, a copy of the training materials and training log with participants to be emailed to LPA by 7/24/24 end of business day (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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/09/2024 03:50 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/09/2024 at 02:28 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(e)
Personnel Records
(e) All personnel records shall be maintained at the facility site.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and attempted record review, the licensee did not comply with the section cited above as LPA asked staff for personnel files and staff stated that they did not have access to files and the person with access is not available to provide files to LPA during todays visit, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Administrator/Licensee to develop a plan where files will be readily available for any future licensing visits. Plan to be sent to LPA by POC due date via email.
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:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2024 03:50 PM - It Cannot Be Edited


Created By: Tena Herrera On 07/09/2024 at 02:38 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: 07/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
(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 as LPA tested hot water temperature in client restroom (in hallway not attached to a bedroom) and water temperature measured at 133.3 degrees F., which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2024
Plan of Correction
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**Staff lowered hot water temperature on water heater during visit**
Licensee/Administrator to create a water temperature log for the next 3 days begining with 7/10/24 and ending 7/12/24, water temperature to be tested morning, day, evening each day and readings must be within regulation. Water temperature log to be emailed to LPA by 7/13/24 (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.
SUPERVISOR'S NAME:David Sicairos
LICENSING EVALUATOR NAME:Tena Herrera
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024


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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: 07/09/2024
NARRATIVE
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The hot water temperature was tested in the client bathrooms and LPA observed water temperature in client restroom (located in hallway that does not join a bedroom) to be outside the required range of 105-120 degrees F, water temperature measured at 133.3 degrees F (citation documented on 809-D).
Operational Requirements: Facility has an activity area furnished for outdoor use. Last fire/earthquake drill was conducted on 6/16/24.
Staffing: There appears to be sufficient staffing at all times in the facility.
Personnel Records-Training: Staff files are maintained in a secure location. LPA was not able to review any staff files during todays visit as staff did not have key to file cabinet that holds staff files, therefore, no staff files were reviewed during visit, administrator (who is the only one with the key) was not available during visit (citation will be detailed in the 809-D)
Client Rights-Information: Facility provides telephone landline and internet for the clients. Client rights posters and reporting posters are displayed within the facility.
Client Records-Incident Reports: Client files are maintained in a secured locked cabinet 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 3 client files with no issues.
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. Medication are in their original containers. During todays visit LPA observed a missed dosage of medication for Client #1, citation will be detailed on 809-D.
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.
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 were provided to Reginald Roy.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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