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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 05/09/2023
Date Signed: 05/09/2023 02:16:56 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
04/27/2023 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: DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
12:44 PM
MET WITH:Maria RamosTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff transporting residents does not have valid California Driver's License.
INVESTIGATION FINDINGS:
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On 5/09/2023 at 12:44 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to deliver findings on the above allegation. Upon arrival, LPA was greeted by staff #1 (S1) and allowed entrance to the facility. LPA met with Maria Ramos the House Manager, and explained the reason for the visit. At approximately 12:46 p.m. LPA conducted an entrance interview via telephone with Administrator Chary Hallon.

Allegation #1: Staff transporting residents does not have valid California Driver's License.
It is alleged the House Manager Maria Ramos does not have a drivers license and is driving residents to various locations. To investigate this allegation, LPA conducted an initial unannounced complaint visit on 05/03/2023. During initial visit LPA conducted interviews between 3:39 p.m. - 4:05 p.m. with two out of four clients present at the facility, S1 and staff #2 (S2) and with the Licensee Asilia Wauls and Administrator Chary Hallon. LPA reviewed facility records and obtained pertinent documents for the investigation.
(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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-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: 05/09/2023
NARRATIVE
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(LIC9099-C Continued)
On 05/09/2023 at 11:16 a.m. LPA interviewed Maria Ramos by telephone. Interview conducted, revealed Maria does not have a California Drivers License, but instead has a California Identification Card. Interviews conducted do not corroborate Maria is transporting residents. Based on record review and interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.


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

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2