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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:33:16 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
03/21/2023 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230321145951
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:
03/27/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria RamosTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
Staff did not intervene in resident on resident incident
INVESTIGATION FINDINGS:
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On 03/27/2023 at 10:00 a.m. Licensing Program Representative (LPA) Evelin Rios conducted an unannounced complaint investigation at the location mentioned above. LPA was greeted by Staff #1 (S1) and granted access. Maria Ramos the house manager met LPA in the entryway. Maria stated they would inform the Administrator, Chary Hallon LPA was here. Present upon LPAs arrival were three (3) out of four (4) clients and two (staff). LPA explained to Maria the reason for the visit. LPA began interviewing Maria when Charry Hallon (Administrator), Jacqueline Page (Administrator for another home), Christopher Singleton (Assistant Administrator), and, Asilia Wauls (Dolly) Licensee entered the home. Licensee designated Maria to sign this report.

LPA conducted interviews with Maria, Chary, and Licensee from 10:05 a.m. to 11:23 a.m. At 11:23 a.m. LPA interviewed S1. From 11:35 a.m. to 12:00 p.m., LPA interviewed Resident #1 (R1) and Resident #2 (R2). At 1:35 p.m. LPA interviewed Staff #2 (S2) by telephone. At 3:45 p.m. LPA interviewed staff #3 (S3) and Resident #3 (R3). (Continued on to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
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-20230321145951
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: 03/27/2023
NARRATIVE
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(LIC 9099-C continued)
Allegation: Staff did not intervene in resident on resident incident.
It is alleged R1 and R3 were involved in an incident where R3 was harassing R1 and staff did not intervene. To investigate this allegation LPA interviewed Maria, S1, S2, S3, R1, R2, R3 and the administrator. Interviews with staff and residents that were present during the incident do not corroborate the allegation. Furthermore there were no more witnesses available at this time to confirm or deny the allegation. LPA also reviewed the Special Incident Report (SIR) for the incident in question and Report Information left by the Lancaster Sheriff Station for R3. Based on interviews conducted and file review, this allegation is Unsubstantiated at this time.

No deficiencies issued at this time. Report signed and delivered. Exit interview.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2