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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 02:58:24 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
06/01/2023 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20230601142516
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:
02:00 PM
MET WITH:Chary HallonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not keep accurate resident records.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct a subsequent unannounced visit to deliver a determination for the allegation 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.

Allegation: Staff did not keep accurate resident records.
In regards to the allegation, it was reported the facility did not have on file records available to North Los Angeles County Regional Center (NLACRC) for review as required. To investigate this allegation LPA conducted an initial visit on 06/02/2023 and interviewed licensee Dolly Wauls and Christopher Singleton administrator assistant. On 06/02/2023 LPA collected documents relevant to this investigation. On todays visit LPA obtained from administrator Chary a copy of the Corrective Action Plan (CAP) provided to facility by NLACRC. (Continued on to 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-20230601142516
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's review of CAP reveled NLACRC did not identify the allegation reported on this complaint as a substantial inadequacy. LPA's interview with licensee on 06/02/2023 revealed facility will be receive a CAP for another incident, mentioned on this complaint. According to Licensee NLACRC provided documents mentioned in this allegation and not be including this allegation on CAP. Based on interviews, document review and LPAs observation this allegation is Unsubstantiated at this time.


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