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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606893
Report Date: 08/14/2023
Date Signed: 08/16/2023 10:26:16 AM


Document Has Been Signed on 08/16/2023 10:26 AM - 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 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:
08/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Manager Tiffany Sasada TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jose Villalobos, conducted a required annual inspection using the Inspection Tool. LPA met with Staff Armando Salvador and the purpose of the visit was discussed. Manager Tiffany Sasada arrived afterwards.

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 cabinet for medications and 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. Theres a laundry area; with washer and dryer. The residence is equipped with central air conditioning. There is a inaccessible fireplace. Accommodations: Adequate accommodations observed throughout facility. Hallway and Doorways: Free and clean of obstruction and debris. Resident Rooms: All bedrooms are equipped with: overhead lighting, chair, night stand, lamp in addition to overhead lighting, large drawer, and closet space. Bathrooms: All bathrooms have a working toilet, wash basin, shower, grab bars and nonskid mats. Linens & Hygiene Supplies: Required linen/supplies observed. Emergency Phone Numbers, Exit Plan & Menu: Facility has a working phone landline. There is a cordless phone for resident use. Fire Extinguisher observed Food Service: All food and adequate utensils such as, dishes, cups, bowls and plates observed. Smoke Detectors & Fire Extinguishers: Detectors Electrical & connected. Battery operated & working, all detectors tested and operational. Toxins: Locked/stored for staff use only. Hot Water Temperature: Measured between 105 -115 degrees all around the home. Medications, First-Aid Kit & Book: Medications centrally stored and inaccessible to residents. First aid kit observed. Postings: Some wall postings observed. Residents & Staff Files: LPA reviewed (5) of (5) Resident medication records and files , as well as four (4) Staff Files . Emergency Disaster Plan observed.



Inspection tool completed and, per Title 22, deficiencies are being cited. 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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/16/2023 10:26 AM - 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
CCLD Regional Office, 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as (3) separate sharp gardining tools were observed in the backyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/15/2023
Plan of Correction
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Deficiency Corrected at the time of Visit. Staff removed the gardening tools and stored in locked area.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/16/2023 10:26 AM - 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
CCLD Regional Office, 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: 08/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above medications for resident #1 were popped from their original packs for the rest of the week and placed in a small medicine container which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2023
Plan of Correction
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Facility will stop using weekly medicine containers and conduct in service training on medication management by POC due date. Proof of training to be submitted to licensing.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 08/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3