Community Care Licensing

Document Has Been Signed on 08/29/2023 11:24 AM - It Cannot Be Edited

FACILITY NAME:	TIFFANY'S BOARD & CARE		FACILITY NUMBER:	197801943
ADMINISTRATOR:	FLORDELIZA SASADA		FACILITY TYPE:	740
ADDRESS:	12326 WHITLEY AVENUE		TELEPHONE:	(562) 692-5877
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90601
CAPACITY: 6		CENSUS: 6	DATE:	08/29/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Flordeliza Sasada - Administrator		TIME COMPLETED:	12:00 PM

SUPERVISORS NAME: David Sicairos LICENSING EVALUATOR NAME: Bennette Pena LICENSING EVALUATOR 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

Link to Parent Document Below:

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 B 09/08/2023 Section Cited CCR 87463(a)(3)(b)	1 2 3 4 5 6 7	Reappraisals ..(a) The pre-admission appraisal shall be updated, in writing... to note significant changes and to keep the appraisal accurate... shall document changes in the resident's physical, medical...condition. Significant changes shall include.. (3) Any illness, injury,,,or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions. (b) The licensee shall immediately bring any such changes to the attention of the resident's physician and his family or responsible person. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will ensure that appraisal shall be updated in writing to note significant changes in the resident's physical, medical, mental, and social condition. 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 (87463 Reappraisals) to CCL/LPA by POC due date.
	8 9 10 11 12 13 14	During the subsequent visit by LPA Pena on 10/19/2022, LPA observed that R1 did not have a reappraisal to note significant changes and update her declining mental/ health issues since mid-June 2022, which poses a potential Health, Safety or Personal Rights risk to the residents in care.	8 9 10 11 12 13 14
Type B 09/08/2023 Section Cited CCR87458(a)	1 2 3 4 5 6 7	Medical Assessment (a) 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. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator will ensure to obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year for all residents in care. Administrator to submit a written statement that she had read, reviewed, and understood Title 22, Division 6 Chapter 8 Article 08. Resident Assessments, Fundamental Services and Right (87458 Medical Assessment) to CCL/LPA by POC due date.
	8 9 10 11 12 13 14	During the subsequent visit by LPA Pena on 10/19/2022, LPA observed that the facility did not have R1’ s current physician report on file which poses a potential Health, Safety or Personal Rights risk to the residents in care.	8 9 10 11 12 13 14

SUPERVISOR'S NAME: David Sicairos LICENSING EVALUATOR NAME: Bennette Pena LICENSING EVALUATOR 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