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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801943
Report Date: 08/29/2023
Date Signed: 08/29/2023 01:55:11 PM

Substantiated


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: 6DATE:
08/29/2023
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Flordeliza Sasada - AdministratorTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility did not meet resident's needs while in care.
INVESTIGATION FINDINGS:
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****This report supersedes the original report dated 10/19/2022. The report is being superseded to change the findings of the above listed allegation from Unsubstantiated to Substantiated. Additional information was obtained during the course of the investigation such as interviews and supportive documentation to support the change in findings.*****
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 and superseded reports with the new findings, as well as cited deficiency. *****CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
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 3
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: 08/29/2023
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." A total of six (6) staff were interviewed and all denied the allegation and stated that staff have been providing care and assistance to R1. R1 resided at the facility from July 3, 2021, until Aug 5, 2022, and needed total assistance with mobility and transfers. S1 stated that R1’s health condition was declining since mid-June of 2022. On 7/20/22, S2 stated that R1 may have suffered a suspected “mini stroke” or TIA but did not call 911 because V1 discouraged her. S2 indicated that R1’s pressure injury opened on 08/02/22 an informed V1. However facility staff did not seek medical attention for R1 at this time even though R1’s condition was declining. S1 informed V1 that R1 may need to go on hospice for more care. On 8/05/2022, tele health appointment with R1’s primary physician with regards to hospice care was conducted and follow up evaluation was scheduled for Sat. 8/6/22 or Sun. 8/7/22. However, on 8/05/2022, S2 noticed that R1 had a temperature and had difficulty breathing. S2 stated that she called and asked V1’s permission to call 911 for R1 who hesitated at first but later agreed. S2 stated that Paramedics and Fire fighters took R1 to the Hospital. 3 days had passed before facility staff seeked medical attention for R1. During interviews, facility staff indicated that they would seek approval from V1 before medical attention for R1 was obtained. LPA’s review of the progress notes indicated that V1 was in regular communication with the facility. 5 out of 5 residents interviewed all denied the allegation and stated that staff take care of their needs. LPA was not able to interview R1 because she never returned to the facility after hospitalization on 8/05/2022 and later passed away in January 2023.

Based on LPA’s observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Exit interview was conducted and deficiency was 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: 08/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2023
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care..(g) The licensee shall immediately telephone 9-1-1 if an injury..imminent threat to a resident’s health..an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
This requirement was not met as evidenced by:
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Administrator will ensure that 9-1-1 shall be called immediately if an imminent threat and/or life-threatening medical crisis to a resident’s health is apparent. Administrator to submit a signed statement that she had read, reviewed, and understood Title 22, Division 6 Chapter 8 Article 08. Resident Assessments, Fundamental Services and Right (87465-Incidental Medical and Dental Care) to CCL/LPA by POC due date.
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Based on the interview conducted, Licensee noticed R1’s change of health condition in mid-June 2022 and on 07/20/23, licensee suspected that R1 had a mini stroke or TIA. However, Licensee didn’t call 911 until 08/05/23 when R1’s pressure injury opened.
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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.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3