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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606893
Report Date: 08/19/2026
Date Signed: 08/19/2026 02:54:20 PM

Document Has Been Signed on 08/19/2026 02:54 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:TIFFANY'S BOARD AND CARE IVFACILITY NUMBER:
197606893
ADMINISTRATOR/
DIRECTOR:		COSTANCE EDWARDSFACILITY TYPE:
740
ADDRESS:16955 JANINE DRIVETELEPHONE:
(562) 690-9274
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY: 6CENSUS: 2DATE:
08/19/2026
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Tiffany Sasada - AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
NARRATIVE
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An Informal Office Meeting was held today in the Monterey Park Regional Office. The purpose of this informal conference meeting is to discuss the high number of uncleared citations issued on the previous two (2) annual inspections conducted on 8/21/2025 and 6/30/2026. Present in the meeting was Licensing Program Analyst (LPA) Erik Zaragoza, Licensing Program Manager (LPM) David Sicairos, and administrator for the facility Tiffany Sasada.

Items discussed included how the facility has addressed the following:
  • Three (3) Uncleared Type A citations on Annual Conducted on 8/21/2025.
  • Six (6) Type B citations issued during the annual conducted on 8/21/2025.
  • Two (2) Uncleared Type A citations on Annual conducted on 6/30/2026.
  • Eleven (11) uncleared Type B citations issued on 6/30/2026.
  • One (1) cleared Type A violation issued on 6/30/2026.
  • One (1) cleared Type B violation issued on 6/30/2026.
  • Pending Planned Change of Ownership (CHOW) for the facility.
  • Concerns in preventing LPA from accessing Bedroom #1 and the Garage for the facility as defined on the current facility sketch.
David Sicairos
Erik Zaragoza
DATE: 08/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TIFFANY'S BOARD AND CARE IV
FACILITY NUMBER: 197606893
VISIT DATE: 08/19/2026
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The facility has stated they will do the following to achieve continued and substantial compliance:
  • Administrator explained that she will submit POCs for all uncleared deficiencies by 8/28/2026.
  • Administrator explained that there are two (2) separate addresses located at the facility, 16955 Janine Dr, Whittier, CA 90603, which is the portion of the licensed property/facility that serves residents, and 16957 Janine Dr, Whittier, CA 90603 which is the residence of the current administrator Tiffany Sasada. Community Care Licensing Division (CCLD) at this time does not have any documentation or proof that these two (2) addresses are separate at this time.
  • Administrator indicated she went to city hall yesterday to obtain documentation that shows 16957 Janine Dr, Whittier, CA 90603 is a separate address, and city hall staff indicated that they would provide documentation showing/proving this by the end of next week. CCLD requested administrator to submit this documentation to LPA as soon as it is received.
  • Administrator stated that moving forward, she will allow CCLD entry to Bedroom #1 and the Garage as indicated on the current facility sketch that CCLD currently has in the facility file.
  • Administrator did not provide any updates on the pending application for the CHOW, because potential applicant Mylyn Castillo is handling the CHOW process with the Centralized Application Bureau (CAB).
  • CCLD discussed with the administrator that an Accessory Dwelling Unit (ADU) or separate address should not prevent the licensure for a Change of Ownership. However administrator and Mylyn Castillo were instructed to contact CAB for further guidance.
  • Failure to correct Plans of Correction (POCs) or failure to pay issued civil penalties could result in administrative action.


Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies issued following the meeting. Exit interview held and a copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2026
LIC809 (FAS) - (06/04)
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