197801943-2-13-2024-28-AS-JVIS-D2EVFK-20240213152403

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197801943
Report Date: 02/13/2024
Date Signed: 02/13/2024 03:24:40 PM

Document Has Been Signed on 02/13/2024 03:24 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	TIFFANY'S BOARD & CARE		FACILITY NUMBER:	197801943
ADMINISTRATOR:	FLORDELIZA SASADA		FACILITY TYPE:	740
ADDRESS:	12326 WHITLEY AVENUE		TELEPHONE:	(562) 692-5877
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90601
CAPACITY:	6	CENSUS: 6	DATE:	02/13/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Administrator Flordeliza Sasada		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analysts (LPA) Jose Villalobos conducted an unannounced Required- 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. The purpose of the visit was explained to Administrator Flordeliza Sasada. The following12 (CARE) tool domains were utilized during the inspection:

Infection Control:

Infection control practices and Personal Protective Equipment (PPEs) were observed. COVID-19 screening is no longer in place. An Infection Control Plan was not observed but requested

Physical Plant/Environment Safety:

The facility is located in a residential area which contains: Living room, kitchen, dining area, 4 Resident bedrooms, 2 bathrooms, laundry area and a detached garage.
The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are enclosed ponds in the backyard. Cleaning supplies and toxic substances are inaccessible.
Water temperature readings measured within title 22 regulations.

Operational Requirements:

A current Plan of Operation observed.
FACILITY IS CLEARED FOR 6 AMBULATORY OR NON-AMBULATORY RESIDENTS. BEDRIDDEN FIRE CLEARANCE APPROVED FOR BEDROOM #3. HOSPICE WAIVER GRANTED FOR 1

Personnel Records - Staff Training:

Administrator on file is current
Staff have criminal background clearances.
Four (4) staff files were reviewed.

Continued on LIC 809-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

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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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 & CARE	FACILITY NUMBER: 197801943
	VISIT DATE: 02/13/2024

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Staffing:

Sufficient staff observed during visit

Resident Records - Incident Reports:

A total of six (6) resident files were reviewed. Required documents observed on file

Resident Rights - Information

Required postings observed

Food Service:

Sanitation practices and kitchen cleanliness was observed.
Kitchen has utensils for clients to use and to store their meals
No cleaning supplies stored near food

Planned Activities:

Sufficient space to accommodate both indoor and outdoor activities was observed.

Incident Medical and Dental:

First Aid Kid observed
(6) of (6) Resident medications reviewed

Disaster Preparedness:

Emergency and Disaster Plan observed

Residents with Special Health Needs:

Currently (1) resident receiving hospice services. Hospice care plans observed

Inspection Tool was completed and no Title 22 deficiencies are being cited on todays visit.
Exit interview conducted and a copy of this report was provided

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 02/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2024

LIC809 (FAS) - (06/04)

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