197610088-4-27-2023-31-AS-MVAO-D242BM-20240202161522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:01:27 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
04/20/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20230420130932

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:	04/27/2023
		UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Maria Ramos		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not ensure that resident was provided with an adequate amount of food.
Staff do not ensure that resident is provided with provisions that were agreed upon when resident moved in.
Staff did not ensure that resident received their medication as prescribed.

INVESTIGATION FINDINGS:

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On 04/27/2023 at 9:48 a.m. Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint investigation at the location mentioned above. LPA was greeted by Maria Ramos and granted access. Present at the facility were Maria, staff #2 and client #1 (C1). Maria Ramos the house manager contacted Licensee and Administrator to inform them LPA was at the facility. The Administrator, Chary Hallon and Licensee Asilia Wauhls met LPA at the faciltiy shortly after. LPA informed Licensee and Administrator the reason for the visit. Licensee and Administrator had to step away and designated Maria to sign this report.

At 10:00 a.m. LPA and Maria conducted a physical plant tour of the facility to ensure the health and safety of the clients in care. LPA did not observe any health and safety issues or concerns. LPA conducted interviews with Maria, S1, staff #2 (S2), Licensee and Administrator from 10:20 a.m. to 12:00 p.m. From 12:00 p.m. to 12:30 p.m. LPA reviewed and obtained documents relevant to this investigation.
(Continued on to LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

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-20230420130932

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: 04/27/2023

NARRATIVE

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(LIC9099-C continued)

Allegation #1: Staff did not ensure that resident was provided with an adequate amount of food.
It is alleged C1 was provided an inadequate amount of food and was refused more food when C1 stated they were still hungry. Interviews with staff corroborate a special incident report (SIR) that occurred 04/19/2023. SIR reveled C1 was asked to serve themselves from larger portions meant for all clients in the facility. C1 touched food with their fingers. S2 asked client to serve themselves with a spoon. C1 became upset and threw the food on the floor. Interview with staff revealed staff did not refuse C1 a meal and instead offered C1 to eat other food that was made. Staff interviews revealed C1 ate later that day. Based on interviews and records review this allegation is deemed to be Unsubstantiated at this time.

Allegation #2: Staff do not ensure that resident is provided with provisions that were agreed upon when resident moved in.
It is alleged C1 is not provide Splenda to accommodate C1's diet as per agreement made between C1 and the facility when C1 moved into the facility. LPA's interview with staff revealed C1 was provided Splenda when C1 had requested it in the past. LPA's review of records revealed Splenda is not an item facility and C1 agreed to in C1's Admission Agreement. Based on interviews and records review this allegation is deemed to be Unsubstantiated at this time.

Allegation #3:Staff did not ensure that resident received their medication as prescribed.
It is alleged C1 was not given new medication as prescribed by C1's physician. To investigate this allegation LPA conducted a review of records, interviewed staff responsible for dispensing medication and observed Maria conduct a pill count. Pill count matched records. Based on interviews, records review and observation this allegation is deemed to be Unsubstantiated at this time.

No deficiencies issued during today’s visit. Report signed and provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 04/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2023

LIC9099 (FAS) - (06/04)

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