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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801943
Report Date: 09/12/2022
Date Signed: 09/12/2022 01:10:11 PM

Document Has Been Signed on 09/12/2022 01:10 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TIFFANY'S BOARD & CAREFACILITY NUMBER:
197801943
ADMINISTRATOR:FLORDELIZA SASADAFACILITY TYPE:
740
ADDRESS:12326 WHITLEY AVENUETELEPHONE:
(562) 692-5877
CITY:WHITTIERSTATE: CAZIP CODE:
90601
CAPACITY: 6CENSUS: 5DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Flordeliza Sasada, Licensee/ administratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced case management visit during the complaint visit 28-AS-20220908154436. LPA met with Flordeliza Sasada at the facility and spoke with Tiffany Sasada, Administrator, via facetime, who both assisted with the visit. The purpose of the visit was to check on the Health and Safety of the Residents and facility. The purpose was discussed with administrator.

On today’s visit LPA conducted a health and safety check. LPA toured the physical plant of the facility and resident file reviews. LPA obtained a copy of the Staff roster and Resident roster.

LPA reviewed resident#1 file and did not observe physician report on file. Administrator explained R1’s physician report was taken by paramedic on 08/05/22 when resident was sent to hospital. Administrator said no R1’s physician report is on file currently.

Deficiencies of Health and Safety were observed per Title 22 Regulations Division 6 Chapter 8. Exit interview was conducted with Flordeliza Sasada, administrator, and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 09/12/2022 01:10 PM - It Cannot Be Edited


Created By: Bonnie Tao On 09/12/2022 at 11:28 AM
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: TIFFANY'S BOARD & CARE
FACILITY NUMBER: 197801943

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/19/2022
Section Cited
CCR
87458(a)

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Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. .. use the form LIC 602 (Rev. 9/89), Physician's Report..
This requirement was not met as evidenced by:
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Administrator would obtain a phyisican report LIC 602 in resident#1's file and provide a copy of the physician report to Licensing by POC due date.
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Resident#1 did not have a current physician report on file.

Based on file review, Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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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:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR SIGNATURE:
DATE: 09/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022


LIC809 (FAS) - (06/04)
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