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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801943
Report Date: 10/19/2022
Date Signed: 08/29/2023 12:57:57 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/08/2022 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220808143000
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:
10/19/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Flordeliza SasadaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility did not meet resident's needs while in care.
INVESTIGATION FINDINGS:
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****This is an amended version of the original report dated 10/19/2022. This report is being amended to remove confidential information that was previously documented on the report dated 10/19/2022. After furtehr review it was also determined that the findings for the above allegation will be changed from unsubstantiated to substantiated. Therefore, the updated findings will be delivered on a separate report during today's visit.*****
Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to deliver the new findings to the above allegation. LPA met with the Administrator, Flordeliza Sasada and explained the purpose of today's visit.
During the initial visit on 8/15/2022 conducted by LPA Bonnie Tao, the investigation consisted of the following: interviewed staff from staff#1 to staff#6, interviewed residents from resident#2 to resident #6 and reviewed records. LPA obtained copies of resident roster, staff roster, resident#1 files, and incident report.
During the subsequent visit on 10/19/2022, LPA Pena interviewed Resident #4 (R4), re-interviewed S1-2 and reviewed R1’s appraisal needs and services plan, resident appraisal, MARs (June-Aug 2022) and incident reports for July-Aug 2022. LPA called RP (11:06am), left a voicemail message requesting a call back.
During today’s visit, LPA delivered the amended report with the new findings and cited deficiency.
*****CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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-20220808143000
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: TIFFANY'S BOARD & CARE
FACILITY NUMBER: 197801943
VISIT DATE: 10/19/2022
NARRATIVE
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The investigation revealed the following: In regards to the allegation " Facility did not meet resident's needs while in care", it is alleged that "Staff called emergency medical services because of R1’s medical condition and medical staff determined that R1’s condition was poor and appeared neglected." Based on the interviews conducted with R2-6 and S1-6 and all denied the allegation. S1-6 indicated that R1 needed assistance on full care of ADL and staff have been providing the care she needed. S2 stated that mid June, she observed that R1’s health condition had changed and was declining since June 2022 and reported it to the family member (V1). S2 stated that she provided care to R1 all the time and made sure that R1’s care is addressed. S2 said to V1 that R1 had an opening/sore on her buttock. S2 advised V1 that R1 needs to be put on hospice for more care. Telehealth appt with R1’s primary physician on regards hospice care was conducted and follow up evaluation was scheduled for Sat or Sun. 8/6/22 or 8/7/22. S2 stated that on 8/05/2022, she noticed R1 had a temperature and had difficulty breathing. S2 called V1 to ask permission to call 911. V1 hesitated at first and wanted to wait for the Nurse to come that weekend but agreed afterwards. S2 stated that Paramedics and Fire fighters took R1 to Hospital. S2 indicated that when she observed R1’s condition changing to the worst, she immediately called V1 and 911 for assistance. Attempts were made by LPAs to contact V1 to determine if she has the right to make medical decision for R1, but unsuccessful.

Although the allegation 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.

Exit interview was conducted and deficiencies were cited. A copy of this report was provided to the Administrator Flordeliza Sasada along with the Appeals Rights.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2