197606893-6-13-2024-28-AS-DKOI-D68238-20240613170154

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606893
Report Date: 06/13/2024
Date Signed: 06/13/2024 05:04:49 PM

Document Has Been Signed on 06/13/2024 05:04 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	TIFFANY'S BOARD AND CARE IV		FACILITY NUMBER:	197606893
ADMINISTRATOR:	COSTANCE EDWARDS		FACILITY TYPE:	740
ADDRESS:	16955 JANINE DRIVE		TELEPHONE:	(562) 690-9274
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	6	CENSUS: 4	DATE:	06/13/2024
TYPE OF VISIT:	Required - 1 Year	ANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Tiffany Sasada, Manager		TIME COMPLETED:	05:20 PM

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	Licensing Program Analysts (LPAs) Daniel Konishi and Christine Wong, conducted a required annual inspection using the Inspection Tool. LPAs met with the Manager, Tiffany Sasada and the purpose of the visit was discussed. Infection Control: The facility has a Infection Control Plan in place. Personal Protective Equipment (PPEs) were observed. The facility continues to practice hand washing and disinfecting. Operational Requirement: Hospice Waiver for 1 is approved. A fire clearance is in place. Liability Insurance in the amount of at least ($1,000,000.00) per occurrence and ($3,000,000.00) in total annual aggregate is in place and expires 07/11/2024. Structure/Physical Plant: The facility is part of a single-story home located in a residential area and contains the following: living room, dining room, kitchen with refrigerator, oven, stove, dishwasher, sink/faucet, locked storage kitchen cabinet for sharps, (3) resident rooms, (2) bathrooms for residents; bathrooms with shower, toilet and washbasin. A back yard with shaded area and seating for resident use. There’s a laundry area; with washer and dryer. The residence is equipped with central air conditioning. There is an inaccessible fireplace. Adequate accommodations observed throughout facility. Hallways free and clean of obstruction and debris. All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Smoke and Carbon Monoxide Detectors Electrical & connected. Battery operated & working, all detectors tested and operational. Toxins are locked/stored for staff use only. Hot Water temperature measured between 109.5 -113 degrees which is within Title 22 Regulation.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024

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 06/13/2024 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TIFFANY'S BOARD AND CARE IV	FACILITY NUMBER: 197606893
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA reviewed Staff#1 does not have health screen and TB test result in the personnel file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	The administrator will send the Staff#1 health screening and TB test result to LPA By POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TIFFANY'S BOARD AND CARE IV	FACILITY NUMBER: 197606893
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87355(e)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, LPA was not able to observe Staff#1 background check paper work and the staff was not associated witht the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	The administrator will send Staff#1 background check clearance paper work and the association to the LPA by POC due date.

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA reviewed the house manager and staff#1 do not have any required training hours or in service training paper work hich poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	The administrator will send the required staff in service training hours for house manger and Staff#1 to LPA by POC due date

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/13/2024 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TIFFANY'S BOARD AND CARE IV	FACILITY NUMBER: 197606893
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468(d)

Personal Rights of Residents

(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, LPA did not observe any resident personal right poster in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	The administrator will send the picture of the personal right poster which has to be posted on the wall to LPA by POC due date

Type B

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPA reviewed Resident#1 does not have pre-admission appraisal in file which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	The administrator will send the residnet#1 pre-admission appraisal to LPA by POC due date

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/13/2024 05:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TIFFANY'S BOARD AND CARE IV	FACILITY NUMBER: 197606893
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPAs did not observe the fire /disaster drill log in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	The administrator will conduct the fire /disaster drill and send the log to LPA by POC due date.

Type B

Section Cited

CCR

87608(a)(5)(A)

Postural Supports

(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, LPAs reviewed that two residents who have the half bed rail beds but does not have any physican order in file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2024
	Plan of Correction
1 2 3 4	The administrator will send the two residents' half bed rail physican order to LPA by POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TIFFANY'S BOARD AND CARE IV	FACILITY NUMBER: 197606893
	VISIT DATE: 06/13/2024

NARRATIVE

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Staffing: There is sufficient number of staffing.

Personnel Records/Staff Training: LPAs reviewed two (2) staff files but Staff #1 does not have health screening, TB Test result and not associated with the faciltiy, and LPA was not able to review staff training hours. Administrator's RCFE Certificate is effective through 06/17/2025.

Resident Rights-Information: Resident personal rights is not posted. Per Administrator, facility provides internet services to all residents and have access to the facility phone.

Planned Activities: Sufficient space to accommodate both indoor and outdoor activities was observed. The facility has a Resident Council. Facility provides equipment and space to accommodate both outdoor and indoor activities.

Food Service: All food and adequate utensils such as, dishes, cups, bowls, and plates observed. Sufficient food supply and emergency food supplies are stored in the kitchen.

Incidental Medical and Dental: Four (4) centrally stored resident medications inaccessible to residents were reviewed; containing 30-day supply of medications. Medical and dental transportation is provided. First aid kit observed.

Resident Records/Incident Reports: Resident files are maintained at the facility. A total of four (4) resident files were reviewed. They contained admission agreements, Physician's Reports, TB clearance. One of the resident was missing the pre-admission appraisal. RCFE complaint poster were observed posted on the wall near the dining area. LPAs did not observe any resident's personal right posted in the facility.

Disaster Preparedness: The facility does not have an updated Emergency and Disaster Plan LIC 610E in place. Records of resident Appraisal and Needs services plans are part of Emergency training.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: TIFFANY'S BOARD AND CARE IV	FACILITY NUMBER: 197606893
	VISIT DATE: 06/13/2024

NARRATIVE

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Residents with Special Health Needs: Currently, one (1) resident is on hospice care and one (1) resident is on home health. Half bed rails for mobility assistance were observed in some resident beds but no physician order in residents' files.

Deficiencies are being cited per Title 22 Regulations. See 809-D page. Exit Interview conducted with Tiffany Sasada and a copy of this report and appeal rights discussed and provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024

LIC809 (FAS) - (06/04)

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