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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197606893
Report Date: 09/15/2020
Date Signed: 10/29/2020 10:40:14 AM



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
06/08/2020 and conducted by Evaluator Shawna Day
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200608141636
FACILITY NAME:TIFFANY'S BOARD AND CARE IVFACILITY NUMBER:
197606893
ADMINISTRATOR:COSTANCE EDWARDSFACILITY TYPE:
740
ADDRESS:16955 JANINE DRIVETELEPHONE:
(562) 690-9274
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 5DATE:
09/15/2020
UNANNOUNCEDTIME BEGAN:
11:39 AM
MET WITH:Tiffany SasadaTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff is not providing comfortable accommodations for residents while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Shawna Day) conducted a subsequent visit to ascertain information pertaining to the above-mentioned allegations and to establish the validity of the complaint.
Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically.
This investigation revealed the following:

STAFF IS NOT PROVIDING COMFORTABLE ACCODATIONS FOR RESIDENTS WHILE IN CARE

During this investigation LPA Day interviewed staff #1 - #3, R#1 and witness. LPA was unable to interview other residents due to their mental capacity. All interviewed were consisted with their statements that staff is always present and available for all residents in placement. The Administrator has children under the age of 18 years of age in the facility and they play ball outside. R#1 and witness informed LPA that they enjoy the children playing ball games they go outside and watch them or join in and throw the ball too.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna DayTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
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-20200608141636
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 AND CARE IV
FACILITY NUMBER: 197606893
VISIT DATE: 09/15/2020
NARRATIVE
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 Based on the information gathered and the interviews conducted the LPA finds that there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

A telephonic exit interview was conducted with Administrator and a hard copy was provided via email for signature
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Shawna DayTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2