<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 05/03/2023
Date Signed: 05/03/2023 05:32:23 PM

Substantiated


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
04/27/2023 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20230427135007
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:
05/03/2023
UNANNOUNCEDTIME BEGAN:
03:38 PM
MET WITH:Charry HallonTIME COMPLETED:
05:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Uncleared adults caring for residents.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 3:38 p.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPA was greeted by staff #1 (S1) and allowed entrance to the facility. LPA later met with Licensee Asilia Wauls "Dolly" and Administrator Chary Hallon an entrance interview was conducted, the purpose of the visit was explained.

LPA conducted interviews between 3:39 p.m. - 4:05 p.m. with two out of four clients present at the facility and S1. At 4:14 p.m. LPA conducted an interview with Administrator and the Licensee Dolly. LPA reviewed facility records and obtained pertinent documents for the investigation. LPA reviewed Facility Personnel Report Summary and identified two out of four staff present have a pending status and were observed to be providing assistance with client care. Administrator Charry reviewed Guardian records and determined staff #2 (S2) and staff #3 (S3) have an in progress status. Administrator provided records to LPA and records indicate S2 and S3 are fingerprint cleared at Wauls Small Family Home.
(Continued on LIC-9099-C)

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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 4
Control Number 31-AS-20230427135007
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
05/04/2023
Section Cited
CCR
80019(e)(1)
1
2
3
4
5
6
7
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(1) Obtain a California clearance or a criminal record exemption as required...This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator will submit to LPA a copy of an email exchange explaining the issue to Guardian by POC date. Administrator will have S1 and S2 not return to the facility until they are cleared.
8
9
10
11
12
13
14
Based on interviews and document review, the Licensee did not ensure that S2 and S3 were cleared to work in the facility. This poses an immediate health and safety or personal rights risk to clients in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 31-AS-20230427135007
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: 05/03/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
(LIC9099-C Continued)

According to the Administrator they made the association and was informed by Guardian clearance status would transfer to this facility.

Per the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, the following deficiency was observed and cited (Refer to LIC 809-D). A civil penalty was assessed and given (refer to LIC421BG).

Deficiencies cited. Exit interview conducted, Appeals rights provided. Report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4