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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801943
Report Date: 01/23/2023
Date Signed: 01/23/2023 03:01:19 PM

Document Has Been Signed on 01/23/2023 03:01 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: 6DATE:
01/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Tiffany Sasada (Administrator)TIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted a site visit for the annual inspection. Upon arriving, LPA met with Tiffany Sasada (Administrator) and explained the purpose of the visit. FACILITY IS LICENSED TO SERVE RESIDENTS AGE OF 60 AND OVER. FACILITY IS CLEARED FOR 6 AMBULATORY OR NON-AMBULATORY RESIDENTS. BEDRIDDEN FIRE CLEARANCE APPROVED FOR BEDROOM #3. HOSPICE WAIVER GRANTED FOR 1

The facility is located in a residential area which contains: Living room, kitchen, dining area, 4 Resident bedrooms, 2 bathrooms, laundry area and a detached garage.

During today’s visit, LPA observed the following: Facility is not operating over capacity or beyond any conditions and limitation on the license. There are no pools or bodies of water on the premises. Facility maintains a comfortable temperature for residents. All outdoor and indoor passageways is kept free of obstruction. Hot water temperature measured between 105 degrees F and 120 degrees F. There is a presence of grab bars for each toilet, bathtub and shower used by residents. Bathtub or shower have non-skid surfaces or stripst. The total daily diet is of the quality and in the quantity necessary to meet the resident’s needs. Minimum of one week supply of nonperishable foods and 2 days of perishable foods was observed. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. The facility ensures sufficient and competent staff to provide the services needed to meet resident needs. Criminal Record Clearance for all required persons is associated to the license. Staff responsible for direct care and supervision have current first aid training. Facility have a disaster and mass casualty plan. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Centrally stored medicines is kept in a safe and locked place.

No deficiencies were observed during today's visit.


An exit interview was conducted and a copy of this report was provided to Tiffany Sasada.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kruz Long
LICENSING EVALUATOR SIGNATURE: DATE: 01/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/23/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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