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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601304
Report Date: 02/14/2023
Date Signed: 02/14/2023 03:20:38 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
02/08/2023 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230208142737
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:
02/14/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mary George- Assistant AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff mismanaging resident medication.
Staff fraudulently completing facility MAR.
Staff do not ensure facility has an adequate supply of food.
Insufficient staffing to meet resident needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an initial unannounced visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Direct Support Professional (DSP) Adina Agent and explained the purpose for the visit. Assistant Administrator Mary George arrived shortly after to assist with the visit.

During the visit, LPA Maldonado obtained a copy of the client/staff roster, conducted a tour of the physical plant with DSP Adina, observed the food supplies,obtained copies of receipts for groceries purchased for January-February 2023, and reviewed client medications for Clients# 1-2, (C1-C2) and the Medication Administration Records (MAR). LPA also conducted intreviews with staff# 1-6 (S1-S6) and obtained the following documents for C1-C2: Facesheet, Physician's Report, Needs and Services Plan.
The investigation revealed the following:

(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20230208142737
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: 02/14/2023
NARRATIVE
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Regarding allegation: Staff mismanaging resident medication.
It is alleged that client's medications are missing due to insufficient staffing. Per interviews conducted, (6) of (6) staff state that client medications are given as prescribed and documented properly on the MAR. All staff stated that if there are any questions or concerns regarding client medications, the facility nurse is contacted to assist in the matter. LPA reviewed (2) client's medications and the MAR and discovered that all medications are being documented properly and given as prescribed. This allegation is unsubstantiated.
Regarding allegation: Staff fraudulently completing facility MAR.
It is alleged that facility staff have been instructed to flush missed client medication dosages down the toilet and still log the missed medications on the facility MAR. (6) of (6) staff state they have never been instructed to flush missed medications or to fraudulently complete the MAR if a medication is missed. All staff stated their policy for this situation is to report missed/refused medications to the facility nurse and then properly dispose of the medication in a box located in the office and complete a destruction log to document it. LPA reviewed the destruction log and discovered that there have been no refused/missed medications in the past month. This allegation is unsubstantiated.
Regarding allegation: Staff do not ensure facility has an adequate supply of food.
It is alleged that the home does not have a sufficient amount of food for the clients in care and staff have had to purchase food for the clients with their own money. LPA observed the food supplies and noted that there is one refrigerator in the kitchen and another in the garage. A variety of different foods was observed in both refrigerators and was sufficient for the (2) clients that are currently in the home- 1 client is currently out of the community. The cupboard in the kitchen also had plenty of non-perishable foods, another cupboard was filled with a variety of snacks, and a rack in the garage was stocked with more non-perishable foods. (6) of (6) staff stated no issues with insufficient food supplies in the facility have ever been experienced. LPA reviewed receipts for groceries purchased for January-February 2023 for the facility and discovered that foods were purchased about once a week and as needed for the home. This allegation is unsubstantiated.
Regarding allegation: Insufficient staffing to meet resident needs.
It is alleged that there is only one staff to cover the night shift, when there should be two. (6) of (6) staff confirmed that there is only (1) staff person to cover the night shift; However, after review of client's physician's reports and Needs and Services Plans, (2) of (3) clients require minimum assistance with their Activities of Daily Living (ADL's). Review of documents also revealed that none of the clients require 1:1 care/supervision. This allegation is unsubstantiated.
Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
LPA did not observe any deficiencies and no citations were issued during today's visit.
An exit interview was conducted with Asst. Administrator Mary George and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2