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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:37:08 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220901092040
FACILITY NAME:TIGERTAIL ADULT HOME 4, INC.FACILITY NUMBER:
197610088
ADMINISTRATOR:HALLON, CHARYFACILITY TYPE:
735
ADDRESS:43418 62ND STREET WESTTELEPHONE:
(661) 433-0625
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:4CENSUS: 4DATE:
09/22/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Asilia Wauls - Licensee TIME COMPLETED:
03:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is refusing to transport resident to the Social Security Office.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 9/22/2022 at 10:30 a.m. Licensing Program Analyst Melissa Ruiz and Angela Panushkina (LPA) arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPAs were greeted by staff and LPAs later met with Licensee, Asilia Wauls. It was alleged that staff is refusing to transport resident to the Social Security office. On 9/8/2022, LPA conducted interviews with the Licensee, Administrator, two (2) staff, and one client (C1). Based on interviews, it was revealed that C1 verbally asked S2 to take C1 the social security office that same day, however C1 told S2 they did not want the Licensee or the Administrator to know this. The Administrator and Licensee confirmed that they had no knowledge of C1’s request to go to the social security office. During today’s visit, Licensee stated that on 9/12/2022, there was a planned outing and asked C1 if they wanted to go to the social security office, and C1 said “No, you’ll never take me.” Based on interviews conducted, this allegation is unsubstantiated at this time. No deficiencies issued at this time. Report signed and delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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