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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 09/07/2023
Date Signed: 09/07/2023 02:01:35 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
08/31/2023 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20230831164845
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:
09/07/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Chary HallonTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal items.
INVESTIGATION FINDINGS:
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On 09/07/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced complaint investigation for the allegation mentioned above. LPA was greeted by staff #1 (S1) and granted access. S1 contacted licensee Dolly Wauls, LPA explained to licensee the purpose of the visit. Administrator, Chary Hallon met LPA shortly after. An entrance interview was conducted.

At approximately 12:00 p.m. LPA interviewed staff present in the facility and resident #1 (R1). At approximately 1:30 p.m. LPA conducted a physical plant tour of the facility and obtained pertinent documents relevant to the investigation.

Allegation: Staff did not safeguard resident's personal belongings
It is alleged a staff member stole resident's #1 (R1) backpack. To investigate the allegation LPA conducted interviews with staff present and one staff #2 (S2) over the phone.
(Continued on LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
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-20230831164845
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: 09/07/2023
NARRATIVE
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LPA also conducted an interview with R1. Interview with licensee and Administrator revealed a few weeks ago they were made aware by R1, R1's backpack was missing and that R1 suspected a staff of stealing it. Interview with R1 states they did not request to record item on LIC621 (Client/Resident Personal Property and Valuables). Administrator corroborates said backpack was not recorded on LIC621 due to R1's refusal to inform staff when they purchase the item and add to LIC621. Interview with S1, the staff member suspected of stealing the backpack denies the allegation. Interviews with staff present in the facility cannot recall seeing the backpack described by R1 in R1's position. Based on record review and interviews, there is insufficient evidence to prove that staff did not safeguard client's personal belongings, therefore the allegation mentioned above is Unsubstantiated at this time.

No deficiency cited. Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2