198601304-10-7-2022-28-AS-MVAO-CK4P3D-20221011105719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198601304
Report Date: 09/12/2022
Date Signed: 10/07/2022 02:26:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/14/2021 and conducted by Evaluator Kruz Long

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210714115919

FACILITY NAME:	BAILEY CARE HOME #4		FACILITY NUMBER:	198601304
ADMINISTRATOR:	SHAWN L. BAILEY		FACILITY TYPE:	735
ADDRESS:	10413 VULTEE AVE.		TELEPHONE:	(562) 622-0806
CITY:	DOWNEY	STATE: CA	ZIP CODE:	90241
CAPACITY:	4	CENSUS: 3	DATE:	09/12/2022
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Shawn Bailey (Administrator)		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff person hit resident.
Resident injured while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kruz Long conducted an unannouned complaint investigation to the facility. Upon arrival, LPA met with Shawn Bailey (Administrator) and explained the purpose of the visit.

During the initial visit conducted on 07/15/21, LPA conducted a health and safety check. LPA toured the facility and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days. Restrooms, handwashing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns during the visit.

During today's visit, LPA interviewed Staff #1 to #4 in the office. An attempt was made to interview Client #2 to #4 but Client#2 is non-verbal, Client #3 and #4 was not avaialble at the facility.

In regards to the allegation: Staff person hit resident. Interviews with 4 of 4 Staff indicate they have never hit a Client nor have they witnessed other Staff hit a Client. Continue to LIC9099C.....

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210714115919

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/12/2022

NARRATIVE

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In regards to the allegation: Resident injured while in care. Interviews with 4 of 4 Staff indicate they have never caused injury to a Client nor have they witnessed other Staff injure a client.

Based on LPA's interviews, the investigation revealed: Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview conducted with Blanca Samayoa and a copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kruz Long
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 09/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2022

LIC9099 (FAS) - (06/04)

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