197610088-2-8-2023-31-AS-EMIR-CQVNKM-20230414103209

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 02/08/2023
Date Signed: 02/08/2023 02:17:30 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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
01/20/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20230120122438

FACILITY NAME:	TIGERTAIL ADULT HOME 4, INC.		FACILITY NUMBER:	197610088
ADMINISTRATOR:	HALLON, CHARY		FACILITY TYPE:	735
ADDRESS:	43418 62ND STREET WEST		TELEPHONE:	(661) 433-0625
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	4	CENSUS: 3	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Chary Hallon		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff do not allow resident to possess personal belongings
Staff did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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On 02/08/2023 at 9:07 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint investigation. Upon arrival, LPA was greeted by staff #1 (S1) and allowed entrance to the facility. LPA later met with the administrator Chary Hallon and the purpose of the visit was explained.

Allegation #1: Staff do not allow resident to possess personal belongings
It is alleged staff confiscated client's #1 (C1) personal belongings and removed 3 to 5 bags of recyclables, 14 newspapers, and a lamp from C1’s bedroom without permission. On 01/24/2023 LPA conducted interviews with the Licensee, Administrator, and two (2) staff. LPA collected C1’s Client/Resident Personal Property and Valuables (LIC 621) which listed items not mentioned in this allegation and signed by C1. On 01/24/2023 LPA observed various newspapers and the lamp mentioned in the allegation in C1's room. Interviews with staff revealed they did remove recyclable plastic bottles from C1's room to prevent insects. According to the staff #1 and staff #2 (S1 and S2) interviewed, bottles contained old milk that had been attracting insects. (LIC 9099 Continued)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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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Control Number 31-AS-20230120122438

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TIGERTAIL ADULT HOME 4, INC.	FACILITY NUMBER: 197610088
	VISIT DATE: 02/08/2023

NARRATIVE

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Facility is storing C1's recyclable plastic bottles in garage and C1 will have to ask staff when C1 is ready to recycle. S1 stated, "C1 has not asked to recycle plastic bottles yet". Based on interviews and LPA's observation this allegation is deemed Unsubstantiated at this time.

Allegation#2: Staff did not safeguard resident's personal belongings
It is alleged C1 is missing $300.00 dollars. The money went missing when C1 went to a water park and the money went missing at the facility. Interview conducted with Licensee on 01/24/2023 revealed they were not aware C1 had any money totaling $300.00. According to the Licensee during the time frame the alleged money went missing C1's family member was the payee but there is an uncertainty about who is the payee. C1 confirms they are working out PNI issues with placement agency. A previous complaint control #31-AS-20221227120123 reveals $300.00 was not mentioned in that earlier complaint involving the same incident in August 4, 2022. Based on record review and interviews, there is not sufficient evidence to prove that staff did not safeguard client's personal belongings, therefore the allegation mentioned above is Unsubstantiated.

Exit interview conducted, report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

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