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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801943
Report Date: 12/07/2023
Date Signed: 12/07/2023 03:26:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/30/2022 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220830151900
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:
12/07/2023
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Flordeliza Sasada TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility did not notify resident's responsible party of a serious injury.
Facility did not provide resident's records to responsible party.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted another visit to deliver the final results of the investigation. LPA met with Administrator, Flordeliza Sasada who assisted with today's visit.

Regarding the allegation that : Facility did not notify resident #1's responsible party of a serious injury. The invesitgation consisted of review of resident #1's file, including facility notes, and interview(s) with Administrator and Staff #1. Resident #1 is no longer residing at the facility, and was not interviewed. Attempts were made to interview resident #1's responsible party. However, LPA was unable to interview resident #1's responsible party. Administrator and Staff #1 stated that they were in constant communication with resident #1's responsible party, and provided facility notes, and text messages to show that they did notify resident's responsible party of resident's injury.

Regarding the allegation that the Facility did not provide resident #1's records to responsible party. The invesitgation consisted of review of resident #1's file, including facility notes, and interview(s) with Administrator and Staff #1. Resident #1 is no longer residing at the facility, and was not interviewed.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
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 2
Control Number 28-AS-20220830151900
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 & CARE
FACILITY NUMBER: 197801943
VISIT DATE: 12/07/2023
NARRATIVE
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Attempts were made to interview resident #1's responsible party. However, LPA was unable to interview resident #1's responsible party. Administrator and Staff #1 stated that they provided resident #1's records to resident #1's responsible party.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted with Ms. Sasada, and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2