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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 06/12/2024
Date Signed: 06/12/2024 12:55:13 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:
06/12/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Maria Reyes (House Manager)TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Uncleared adults caring for residents
INVESTIGATION FINDINGS:
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The reason for today’s subsequent visit is to correct the deficiency issued on 5/3/2023. LPA cited the incorrect section 80019(e)(1) and assesed a civil penalty LIC421BG (Without a criminal record clearance or exemption.) On this report LPA is citing the correct deficieny section 80019(e)(3) and assessing civil penalty (Without a clearance transfer or exemption transfer.) The findings of Substantiated for the above allegation will remain the same. LPA also provided clarification on the (2) two individuals in question. S2 and S3 were previously cleared, but not associated to this facility at the time. LPA met with Maria Reyes the house manager. Maria contacted the administrator Chary Hallon and LPA explained the purpose of today's visit. Chary designated Maria to sign today's report.

On 05/03/2023 att 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. (LIC9099-C Continued)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
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 3
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: 06/12/2024
NARRATIVE
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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 (2) out of four (4) staff present have a pending status and were observed to be providing assistance with client care. Administrator Chary 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 a licensed facility. According to the Administrator they made the association and were informed by Guardian clearance status would transfer to this facility. Based on record review, S2 and S3 have background clearance, but have pending status for association to this facility therefore the allegation is substantiated at this time.

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 (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: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 06/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/12/2024
Section Cited
CCR
80019(e)(3)
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(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:(3) Request a transfer of a criminal record clearance as specified in Section 80019(f)...This requirement is not met as evidenced by:
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POC was cleared on 05/04/2023.
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Based on interviews and document review, the Licensee did not ensure that S2 and S3 were associated to this facility before they provided care to clients. Although S2 and S3 are background cleared the facility did not ensure a transfer of criminal record clarence as required by the department, was completed which poses an immediate health and safety or personal rights risk to clients in care.
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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: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3