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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 02/15/2023
Date Signed: 02/15/2023 11:33:03 AM

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
02/09/2023 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230209123712
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: 3DATE:
02/15/2023
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Asilia Wauls - LicenseeTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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9
Facility staff not putting in request for resident’s money.
INVESTIGATION FINDINGS:
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At 9:24 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility in response to the above mentioned allegation. LPA was granted entry into the facility by staff Maria Ramos. LPA met with Asilia Wauls, Licensee shortly after and explained the reason for the visit. Asilia could not stay to sign this report and designated Maria to sign report.

Allegation: Facility staff not putting in request for resident’s money.
It is alleged the administrator is not putting in request for R1 to receive PNI money. To investigate the allegation, on 02/15/2023 at 09:30am, LPA interviewed Licensee and North Los Angeles County Regional Center (NLACRC) Services Coordinator Claudia Flores over the phone. LPA also requested and reviewed facility records. Interview with Claudia confirmed she had spoken with F.A.C.T. an organization contracted by NLACRC to manage money made out to payees and according to Claudia the documents were submitted and being processed by F.A.C.T. Money will be dispersed on schedule no later then by end of this week. Licensee also confirmed F.A.C.T. will send money by end of this week. (LIC 9099 Continued)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20230209123712
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: 02/15/2023
NARRATIVE
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Licensee states they submitted the paperwork as soon as they were notified by NLACRC they needed to designate a payee and send request to F.A.C.T. Request was made 02/10/2023. Based on interviews conducted this allegation is Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of this report was provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2