197610088-11-21-2023-31-AS-EMIR-DB7NB6-20241120091833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 11/21/2023
Date Signed: 11/21/2023 12:28:22 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
11/15/2023 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20231115140817

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:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Asilia Wauls /Licensee		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not safeguard resident’s personal belongings.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

At 9:20 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced complaint visit. House manager Maria Ramos granted access and contacted the administrator and informed them LPA was at the facility. Licensee, Asilia Wauls made contact and informed LPA they would arrive later at the facility. Present at the facility upon entry was client #1 (C1), client #2 (C2), client #3 (C3) and client #4 (C4). C3 and C4 left the facility shortly after with staff. LPA interviewed C2 at approximately 9:40 a.m. before they left to their Day Program. LPA interviewed the staff at the facility at approximately 10:00 a.m.

At approximately 10:25 a.m. LPA conducted a physical plant inspection to assure the health and safety of the residents in care. LPA also conducted file reviews and obtained copies of pertinent documents. At approximately 10:40 a.m. LPA interviewed C1 At 10:53 a.m. Licensee arrived to the facility. LPA interviewed licensee. Allegation: Facility staff did not safeguard resident’s personal belongings. It is alleged staff is entering C1's room when they are not present, C1's electric shaver and toothbrush were stolen and a knife was found under C1's pillow with C1's name taped to the knife. (Cont. on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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-20231115140817

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: 11/21/2023

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

To investigate the allegation LPA conducted interviews with clients and staff. Interview with C1 revealed they were told by staff the electric shaver cannot be stored in their room and C1 went on to say the electric shaver is stored by staff. LPA observed C1's electric shaver locked in a closet where the medication and sharp items are kept. C1 also informed LPA the police were called when the knife was found and when police arrived they lifted the pillow and it was no longer under the pillow. C1 states they have seen the knife before kept locked in the medication closet. LPA observed two electric toothbrushes on C1's dresser. C1 stated those were not the toothbrushes that went missing. C2 interview denied the allegation. Staff interviews deny the allegation. Staff corroborate they did enter the room without C1 present in order to throw out old spoiled food that C1 will not allow them to take out of the room. Interview with licensee revealed items C1 brings are closed in bags and have a strong odor. When staff went in to clean they did so for health a safety reasons. LPA referred to complaint control number 31-AS-20230831164845 with the same allegation as staff state C1 does not inform them when they bring in items from the outside and therefore staff are unable to document items. Based on interviews and observations there is insufficient evidence to prove that facility staff did not safeguard resident’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: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2