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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 04:58:50 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-20230317164505
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:
05:00 PM
ALLEGATION(S):
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Staff are not meeting the dietary needs of resident in care.
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 Ramos to sign for this report.

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 (S32 by telephone. LPA interviewed Staff #3 (S3) and Resident #3 (R3) at 3:45 p.m. (Continue 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-20230317164505
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: Staff are not meeting the dietary needs of resident in care.
It is alleged staff are only providing starchy foods and are not providing substitutions for pork in meals.
To investigate this allegation LPA conducted interviews with Maria, R1 and R2. LPA reviewed facility records which revealed no dietary restrictions for R1. Interview with Licensee revealed they have reached out to R1's physician to determine if R1 should be on a restrictive diet. According to Licensee, R1 has only been recommended to make healthy decisions when it comes to R1's diet. LPA conducted a physical plant tour of the facility and observed foods and liquids with low sugar. LPA observed yogurt, granola, almond milk and white bread in resident's room. LPA observed sweet snacks in a closet and pork products in the fridge and facility menu. Interview with Maria revealed they purchase food R1 requests whenever possible and will replenish R1's food when R1 is running out of a certain kind. Maria states R1 will ask for a particular food item even when they still have plenty of it. Maria states staff offer a substitute of food whenever pork is in the menu and R1 has his own pans. R1 is able to purchase own food and receives PNI to make own purchasing decisions. 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)
Page: 2 of 2