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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197801943
Report Date: 03/22/2024
Date Signed: 03/22/2024 01:23:41 PM

Document Has Been Signed on 03/22/2024 01:23 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:
03/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Staff#1, caregiverTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Tao conducted an unannounced case management visit during the complaint visit 28-AS-20220908154436. LPA met with staff#1 (S1) caregiver at the facility and spoke with Lynn Sasada, Administrator to discuss the purpose of the visit. The purpose of the visit was to check on the Health and Safety of the Residents and facility.

LPA toured the physical plant of the facility and staff file reviews. LPA obtained a copy of the staff/resident roster.

LPA reviewed resident#1 file and did not observe physician order for oxygen administration on file. Administrator explained R1’s physician report was taken by paramedic on 8/5/22 when resident was sent to hospital. Administrator said no R1’s physician order for oxygen administration or physician report was currently on file.

Deficiencies of Health and Safety were observed per Title 22 Regulations Division 6 Chapter 8. Exit interview was conducted with staff and a copy of this report, LIC 809D, and appeal rights were provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Bonnie Tao
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/22/2024 01:23 PM - It Cannot Be Edited


Created By: Bonnie Tao On 03/22/2024 at 11:05 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
03/29/2024
Section Cited
CCR
87618(b)(1)

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(b)(1)…licensee shall be responsible for...(1) monitoring of the resident's ongoing ability to operate the equipment in accordance with the physician's orders.

This requirement was not met as evidenced by:
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Administrator would obtain a physician order of oxygen administration for resident#1 or provide a statement explaining why Licensee could not obtain a physician order and how to prevent it from happening in the further. Due by POC due date.
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Resident#1 did not have a physician order for oxygen administration on file.

Based on file review, Administrator did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Bonnie Tao
LICENSING EVALUATOR 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


LIC809 (FAS) - (06/04)
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