197610088-3-27-2023-31-AS-EMIR-CZR26F-20240122160705

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 03/27/2023
Date Signed: 03/27/2023 04:46:14 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
03/17/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20230317115222

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: 4	DATE:	03/27/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Maria Ramos		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff do not allow clients to have access to drinking water
Staff do not ensure there is an adequate supply of food for clients
Staff do not ensure client has proper clothing

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) in the home. 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.

LPA conducted interviews with Maria, Administrator, 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. LPA interviewed Staff #3 (S3) and Resident #3 (R3) at 3:45 p.m.
(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)

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Control Number 31-AS-20230317115222

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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(LIC9099-C continued)
Allegation #1: Staff do not allow clients to have access to drinking water.
It is alleged a few days ago R2 spilled water while trying to pour from a 5 gallon bottle. Since then staff have locked away the 5 gallon of water bottles that were initially kept by a couch in the home available to residents. To investigate this allegation, LPA conducted interviews with Maria, R1 and R2. Maria confirms 5 gallons are kept locked in closet to prevent injury when residents try to pour water for themselves. According to Maria, pitchers are filled with water by staff so that residents may pour themselves water out of smaller pitcher of water then the 5 gallon bottles. R1 and R2 corroborate water is available to them. LPA conducted a physical plant tour and observed one (1) pitcher of water and one (1) pitcher of water with juice mix available to clients in the kitchen. Furthermore LPA observed two (2) pitchers of water in R1's bedroom. Based on interviews conducted and LPA's observation, this allegation is Unsubstantiated at this time.

Allegation #2: Staff do not ensure there is an adequate supply of food for clients.
It is alleged residents have a food budget of $50-$60 every two weeks but the staff are not buying enough food. To investigate this allegation, LPA conducted interviews with Maria, R1 and R2. LPA also conducted a physical plant tour of the kitchen and resident's rooms. Interview with Maria revealed staff purchase the bulk of the groceries every two weeks and for items like vegetables that they use often on a weekly bases. During physical plant tour LPA observed a sufficient amount of 2 day perishable and 7 day non-perishable food supply for residents in care. Interview with one (1) of the (4) residents in care revealed they do not like the snacks and meals provided by staff and will instead make their own meals. Maria corroborates resident has refused meals. Based on interviews conducted and LPA's observation, this allegation is Unsubstantiated at this time.

Allegation #3: Staff do not ensure client has proper clothing.
It is alleged staff refuse to buy R1 new shoes and undergarments. To investigate this allegation, LPA conducted interviews with Licensee and R1. LPA review of facility files, revealed, although Licensee is safeguarding PNI, R1 has access to and is responsible for managing their own money once they receive it. Furthermore review of the facility files revealed R1 had signed off they received cash on various days through out March 2023 to make their own purchases. Based on interviews conducted and record 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)

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