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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606893
Report Date: 06/30/2026
Date Signed: 06/30/2026 05:29:07 PM

Document Has Been Signed on 06/30/2026 05:29 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:
06/30/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Mylyn Castillio - DSP TIME VISIT/
INSPECTION COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Mylyn Castillo, caregiver for the facility, and explained the purpose of the visit. Administrator Tiffany Sasado was notified of the visit by phone call.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control plan was not present in facility.



Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. The facility consists of four (4) resident bedrooms, a multipurpose room, a kitchen, dining room, a living room, and two (2) resident bathrooms which both fell within the required range of 105 – 120 degrees Fahrenheit. The carbon monoxide detector is operational in the home. A fully charged fire extinguisher is kept on the premises.


· LPA was not permitted to inspect Bedroom #1 or the garage of the facility. Administrator claims that this is a separate address, however it is still part of the same address according to the facility sketch and plan of operation that is held with the licensing agency.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/30/2026
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 14
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)
Page: 2 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.32
Regulations
Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and observation, the licensee did not comply with the section cited above in 2 out of 2 residents, because LPA did not allow LPA to enter Bedroom #1 or the Garage identified in the facility sketch which is from the facility file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Administrator is to allow the licensing agency to inspect all areas of the facility at all times. Administrator shall review the regulation and confirm this to LPA by email, and email LPA the facility's plan on how the Bedroom #1 and the garage will be excluded from the operating portion of the facility, including an updated facility sketch, to LPA by the POC due date.
Type A
Section Cited
CCR
87355(e)(3)
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: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff members, because S2 and S3 do have criminal background clearances, however their association has not been transferred to this facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Administrator is to ensure staff are associated to the facility prior to working at all times. Administrator shall submit the facility's plan to associate S2 and S3 to Guardian to LPA by the POC due date. Administrator shall follow up with LPA once the association of the two staff members is completed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 3 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in 1 out of 2 residents, because R2 has full-length bedrails however they are not on hospice, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2026
Plan of Correction
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Administrator is to ensure only residents on hospice have full-length bedrails on their beds at all times. Administrator shall email LPA the facility's plan to either remove the full rails, or install half-rails for the resident and obtain a physician's order for R2 by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 4 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review,, the licensee did not comply with the section cited above in 2 out of 2 residents, because the facility did not have an infection control plan LIC9282 on file during the visit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator is to ensure that an infection control plan remains on file at all times.
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 2 out of 2 residents, because the current facility sketch that the licensing agency has on file includes a Bedroom #1 which is now where the administrator of the facility lives, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator is to ensure that the facility sketch is updated with the licensing agency at all times. Administrator shall email LPA the facility's updated and current facility sketch and to LPA by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 5 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)(1)
Reporting Requirements
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on interview and record review, the licensee did not comply with the section cited above in 1 out of 3 residents, because R3 passed away on 6/23/2026, however no death report was submitted to the licensing agency which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator is to ensure that death reports are emailed to the licensing agency within the appropriate time frames at all times. Administrator is to submit the death certificate to the licensing agency by the POC due date.
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, the licensee did not comply with the section cited above in 1 out of 2 residents, because the bathroom in R1's room is missing a window screen, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator is to ensure that window screens are maintained on all windows that open in the facility at all times. Administrator shall install a window screen in R1's restroom and email photographic proof to LPA by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 6 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468(c)(2)(A)
Personal Rights of Residents
(c) Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the Residential Care Facility for the Elderly (RCFE) Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, the licensee did not comply with the section cited above in 2 out of 2 residents, because the PUB 475 See something Say Something poster is not posted in the facility, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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4
Administrator shall ensure that the PUB 475 poster is posted within the facility at the appropriate dimensions at all times. Administrator shall post the poster in the facility and email LPA proof it has been submitted by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 7 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff members, because there was no documented training on topics related to dementia care, hospice care, postural supports, or restricted health conditions, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
1
2
3
4
Administrator shall ensure that all staff members receive training pertaining to dementia care at all times. Administrator shall conduct the required training amongst S2 and S3, and email the doucmented training to LPA by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 8 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 residents, because R2 did not have a pre-admission appraisal in their file, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
1
2
3
4
Administrator is to ensure that pre-admission appraisals are conducted for residents at all times. Administrator shall conduct an appraisal for R2 and email the appraisal to LPA by the POC due date.
Type B
Section Cited
CCR
87458(c)(1)(D)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (D) Other medical conditions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 residents, because R1 does not have an updated LIC602A (4/25) physician's report, they instead have the older LIC602A (8/11) which is incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
1
2
3
4
Administrator shall ensure that residents have the current LIC602A form in their file at all times. Administrator shall obtain and updated physician's report for R1 and submit it to LPA by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 9 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 2 residents, because R1 did not have a reappraisal conducted within the past 12 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
1
2
3
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Administrator is to ensure that reappraisals are conducted at least every 12 months at all times. Administrator is to conduct a reappraisal for R1 and email it to LPA by the POC due date.
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
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 residents, becuase there was no documented disaster drill conducted within the past 3 months, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator is to ensure that disaster drills are conducted and documented at least every 3 months. Administrator shall conduct a disaster drill, document the drill and the type of disaster it covered, and email the drill to LPA by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 10 of 14
Document Has Been Signed on 06/30/2026 05:29 PM - It Cannot Be Edited


Created By: Erik Zaragoza On 06/30/2026 at 03:51 PM
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 AND CARE IV
FACILITY NUMBER: 197606893

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/30/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 residents, because there was not an updated 9-page LIC610E (12/25) disaster plan on file, only the single-page older LIC610E (10/03), which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/24/2026
Plan of Correction
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Administrator is to ensure that an updated LIC610E is documented and kept on file at all times, and reviewed yearly which shall be documented. Administrator shall complete the current 9-page LIC610E and email it to LPA by the 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
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Based on observation, the licensee did not comply with the section cited above in 1 out of 2 residents, because R1 has half-bed rails but does not have a physician order for the rails, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Administrator is to ensure that all residents half physician orders for residents that have half-bed rails at all times. Administrator is to either obtain a physician's order for the rails or remove the rails for the resident by the 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.
David Sicairos
NAME OF LICENSING PROGRAM MANAGER:
Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/30/2026


LIC809 (FAS) - (06/04)
Page: 11 of 14
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: 06/30/2026
NARRATIVE
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·The facility sketch located in the facility, does not match with the current facility sketch on file with the licensing agency. It has since removed Bedroom #1 and the garage, but the licensing agency does not have this on file nor has received it.
· One (1) resident’s (R1’s) bathroom does not have a window screen in their bathroom.

Operational Requirements:

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents, and a hospice waiver approved for one (1) residents.

· Care and supervision to meet the clients’ needs was observed.


· There is currently no PUB 475 poster “See something Say something” poster located in the facility.

Staffing:

· Five (5) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.


· All five (5) staff records have a health screening with a Tuberculosis clearance, First Aid/CPR trainings that are active, and required annual trainings.
· Two (2) staff members (S2 and S3) do not have documented training on file pertaining to dementia care, postural supports, hospice care, and restricted health conditions.
· Two (2) caregivers (S2 and S3) who work at the facility are not currently associated to the facility, and need to be transferred from their previous facility.
· Administrator’s certificate expires on 1/31/2028.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC809 (FAS) - (06/04)
Page: 12 of 14
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: 06/30/2026
NARRATIVE
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Resident Rights/Information:

· Physician orders were reviewed for five (5) resident files.

· Medications were also reviewed for five (5) residents.

· A death report was not submitted to the licensing agency for one (1) resident (R3), who passed away on 6/23/2026.

Resident Records/Incident Reports:

· Five (5) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.


· One (1) Resident (R1) has not had a reappraisal conducted within the past twelve (12) months.
· One (1) Resident (R2) does not have a Pre-Admission Appraisal on file and were admitted this year.
· One (1) Resident (R1) does not have a current LIC602A (4/25) on file, and the one they do have is not fully completed.

Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.


Incident Medical and Dental:

· All residents have are assisted with medication management by staff.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC809 (FAS) - (06/04)
Page: 13 of 14
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: 06/30/2026
NARRATIVE
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Disaster Preparedness:

· Emergency and Disaster Plan (LIC610E) that is posted in the facility is the older single-paged LIC610E form, it is not the current LIC610E form that is 9-pages.

· The last emergency and disaster drill was not documented within the past three (3) months.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

· One (1) resident (R1) has half-rails on their bed, however they do not have a physician’s order for the rails.

· One (1) resident (R2) has full-rails on their bed, however they are not on hospice.


Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D pages. Civil Penalties were issues on the LIC421IM, LIC421BG, and LIC421FC pages. Exit interview held and a copy of the report along with appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2026
LIC809 (FAS) - (06/04)
Page: 14 of 14