<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197801943
Report Date: 03/22/2024
Date Signed: 04/05/2024 11:58:12 AM

Substantiated


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
09/08/2022 and conducted by Evaluator Bonnie Tao
COMPLAINT CONTROL NUMBER: 28-AS-20220908154436
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:
03/22/2024
UNANNOUNCEDTIME BEGAN:
08:32 AM
MET WITH:Staff#4, caregiverTIME COMPLETED:
10:15 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained a stage 4 pressure injury while in care.
Resident was diagnosed with sepsis and E-Coli.
Staff did not seek medical attention to resident in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
***This report serves as an amendment and supersedes the complaint investigation report dated 03/07/24. The purpose of the visit is to correct the deficiency page. The findings remain as Substantiated. ***

On today visit, Licensing Program Analyst (LPA) Tao conducted a subsequent complaint visit met with staff#4, caregiver. The purpose of the visit was to correct the complaint deficiency cited on 03/07/24 for the Stage 4 pressure injury and to add the additional citation for neglect.

On 09/12/22, Licensing Program Analyst (LPA) Tao conducted the initial complaint investigation for the allegations listed above. LPA Tao conducted a health and safety check and toured the facility with Licensee, Flordeliza Sasada. LPA observed the facility was clean and in good repair, had a minimum of one-week nonperishable foods and a minimum of two days of perishable foods, and had operable wash basins, showers/bathtubs, and toilets and LPA did not observe any immediate health and safety concerns.
(-continued in LIC 9099C-)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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 6
Control Number 28-AS-20220908154436
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: 03/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***This report serves as an amendment and supersedes the complaint investigation report dated 03/07/24. The purpose of the visit is to correct the deficiency page. The findings remain as Substantiated. ***

On 11/18/22, a subsequent tele-visit was conducted by Investigator Brian Slatic, during the visit, Investigator Slatic interviewed staff from staff#1 (S1) to staff #4 (S4) which included Administrator/Licensee; interviewed resident’s representative (RR) from RP1 to RP3; interviewed local law enforcement (P1); obtained resident records from hospital and obtained records from local law enforcement. IB reviewed resident#1 (R1)’s facility file and any related documentation.

On 03/07/24, LPA Tao conducted a subsequent visit to deliver findings. On 03/22/24, LPA Tao conducted another visit for the purpose to correct the complaint deficiency cited on 03/07/24 for the Stage 4 pressure injury and to add the additional citation for neglect.

Regarding allegation: resident sustained a stage 4 pressure injury while in care. It was alleged that due to staff neglect, a resident had a stage 4 pressure injury on resident’s Sacro Coccyx area while in care. During the investigation, the department interviewed staff from S1 to S4, responsible party (RP) from RP1 to RP3, and Whittier Police Department. The department reviewed R1’s facility file and reviewed R1’s hospital records. Per interviews with staff, on 07/31/22, staff #1 observed R1’s buttock area was a little raw. On 08/02/22, staff #1 observed R1s sore opened up and R1’s responsible party was notified. On 08/04/22, staff #1 indicated R1’s coccyx area had skin peeling off and outer area was reddened and staff notified R1’s responsible party. On 08/05/22, staff reported R1’s pressure sore was equivalent to the size of a quarter coin. On the same day, R1 developed a severe fever of 100-degree Fahrenheit and staff notified R1’s responsible party. R1 was sent to hospital for observation and treatment. Upon admission to the hospital, R1 was diagnosed with a Stage 4 pressure ulcer. R1’s sore was as extremely large and required surgery. On 08/07/22, R1 had surgery at the hospital. Per R1s file review, on 7/31/22, R1 had redness on buttocks, however, the facility did not address or document R1’s pressure injuries on R1’s care plan and R1 had not been admitted to hospice or R1 had not undergone a hospice evaluation. The facility had contacted a hospice nurse to schedule an evaluation of R1, however, R1 was not evaluated by Hospice until around 08/06/22 or 08/07/22. Thus, R1 developed a prohibited health condition, a stage IV pressure injury to the Sacro-Coccyx area, which was unstageable. Therefore, staff retained R1 with a prohibited health condition and failed to ensure R1 pressure wound was treated by a licensed medical professional.
(-continued in LIC 9099C-)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 28-AS-20220908154436
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: 03/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***This report serves as an amendment and supersedes the complaint investigation report dated 03/07/24. The purpose of the visit is to correct the deficiency page. The findings remain as Substantiated. ***

Regarding allegation: resident was diagnosed with sepsis and E-Coli. It was alleged that R1 had sepsis and E-Coli while in care. The department reviewed R1’s hospital records. On 08/05/22, R1 was sent to for evaluation at a local hospital due to R1 being hot to the touch and having a fever. Upon admission to the hospital, R1’s medical records and lab results indicated R1 had severe sepsis and E coli. The facility staff were aware of R1’s mental and health decline over the past four days prior to the hospital admission.

However, the staff did not seek and/or provide R1 with immediate medical assistance, despite R1 changes of condition. Therefore, staff failed to obtain medical treatment for R1 who upon admission to the hospital was diagnosed with Sepsis and E Coli.

Regarding allegation: staff did not seek medical attention to resident in a timely manner. It was alleged that staff did not provide a resident with medical attention timely. The department interviewed staff. Per staff interviews, on 07/31/22, the facility staff were aware of R1 had was raw on R1’s buttock. On 08/02/22, the staff observed R1’s change of condition. Per staff, R1’s pressure wound/sore on Sacro-Coccyx was observed to be raw and the R1’s pressure wound had opened up. Staff notified R1’s family/authorized representative about the R1’s opened pressure wound/sore. R1 was scheduled to have a hospice evaluation on 08/06/22. However, on 08/05/22, R1 had a severe fever and R1’s wound on the Sacro Coccyx opened up. Staff reported R1’s sore to be equivalent to the size of a quarter coin. As mentioned above, R1 was hot to the touch and the facility staff noted R1’s fever. R1 was physically and mentally declining over the past four days. As a result, on 08/02/22, R1’s had a change of condition, on 08/05/22, R1 was sent to hospital for evaluation and treatment. Upon admission to the hospital, R1’s medical records indicated R1 had sepsis, E-Coli, and stage 4 pressure injury. Per R1’s record review, the R1’s pressure injury was around the size of a basketball and down to the bone. Therefore, staff were aware of R1’s changes of condition on 08/02/22, however, staff neglected to seek timely medical attention for R1 until 08/05/22, upon which R1 required surgery for R1’s pressure wound.

(-continued in LIC 9099C-)
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 28-AS-20220908154436
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: 03/22/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
***This report serves as an amendment and supersedes the complaint investigation report dated 03/07/24. The purpose of the visit is to correct the deficiency page. The findings remain as Substantiated. ***

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, and Chapter 8), are being cited on the attached LIC 9099D.

An immediate $500 civil penalty is being issued during today's visit due to the neglect/lack of care and supervision resulting in resident sustaining a stage IV pressure injuries.

The licensee was informed that a civil penalty might be assessed based on the Health & Safety Code 1569.49(e) or (f), or 1548(e) or (f), or 1568.0822(e) or (f).

Exit interview conducted with Staff#4. Appeal Rights was discussed and a copy was given during visit
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 28-AS-20220908154436
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2024
Section Cited
CCR
87615(a)(1)
1
2
3
4
5
6
7
(a) Persons who require health services for...shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/ Administrator agrees to submit a written statement of how this deficiency will be corrected and prevented by the POC due date.
8
9
10
11
12
13
14
Based on record review & staff interviews, the licensee retained a resident with a prohibited health condition (Stage 4 pressure injury) who was not on hospice, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type A
03/25/2024
Section Cited
CCR
87468.2(a)(8)
1
2
3
4
5
6
7
(a)(8) …residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:.. (8) To be free from neglect,…

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Licensee/ Administrator agrees
(1) to conduct staff training on regulation 87468.2 and provide proper medical care to pressure injuries residents as required.
(2) to submit a written statement of how this deficiency will be corrected by the POC due date.
8
9
10
11
12
13
14
Based on record review & staff interviews, the licensee did not comply with the section cited above and provide care by medical professional to resident#1 who had stage 4 pressure injuries, sepsis and E-Coli which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 28-AS-20220908154436
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2024
Section Cited
CCR
87465(a)(1)
1
2
3
4
5
6
7
(a)(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement was not met by evidence of:
1
2
3
4
5
6
7
Licensee/ Administrator agrees to conduct staff training on regulation 87465, provide proper medical care which includes pressure injuries for residents as required. Licensee agrees to submit a written statement of how this deficiency will be corrected by the POC due date.
8
9
10
11
12
13
14
Based on interviews and record reviews, Administrator failed to seek timely medical attention for resident#1 when resident sustained stage 4 pressure injuries, which poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Additionally, Licensee will submit proof of staff training which includes staff signatures and dates by 4/5/24.
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Bonnie Tao
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6