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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 07/02/2024
Date Signed: 07/02/2024 04:19:03 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
05/24/2023 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20230524161001
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:
07/02/2024
UNANNOUNCEDTIME BEGAN:
02:22 PM
MET WITH:Chary HallonTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff failed to meet resident's needs.
Staff refused to assist resident.
INVESTIGATION FINDINGS:
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On 07/02/24 Licensing Program Analyst (LPA) Evelin Rios conducted a subsequent unannounced complaint visit to continue investigating the above allegations. At 2:21 p.m. LPA met with the administrator, Chary Hallon and explained the purpose of the visit. Entrance interview conducted.

LPA conducted a physical plant tour to ensure the health and safety of the clients in care. No issues or concerns were observed.

To investigate the allegations, an initial visit was conducted by LPA Rios on 06/02/23. On 06/02/23 at 1:00 p.m., LPA Rios arrived at the facility to conduct an unannounced complaint visit. Upon arrival, LPA knocked on the door and nobody answered. LPA contacted Licensee Asilia Wauls via telephone, LPA informed licensee reason for the visit. Licensee informed LPA they will have someone meet LPA at the facility. Staff #1 (S1), and Licensee, Asilia Wauls met LPA shortly after. (Cont. to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 31-AS-20230524161001
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: 07/02/2024
NARRATIVE
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Staff#2 (S2), Staff #3 (S3), resident #2 (R2), resident #3 (R3) and resident #4 (R4) arrived at the facility while LPA was conducting initial investigation. From 1:50 p.m.to 3:20 p.m. LPA interviewed licensee, staff and R2. R3 and R4 did not respond to LPA's questioning. From 3:21 p.m. to 4:13 p.m. LPA collected documents relevant to this investigation such as resident #1’s (R1)’s physician’s report, Individual Program Plan (IPP), Facility’s quarterly reports in regard to R1 and R1’s admission agreement. On 09/07/23 and on 07/02/24 LPA interviewed resident #1 (R1).

Allegation#1: Staff failed to meet resident's needs. It is alleged resident #1 (R1) is not getting appropriate care. Interview with R1 on 07/02/24 revealed when another resident is having an “unruly” behavior the staff is unable to leave the facility when R1 wants to because staff stay at the facility to provide assistance with the resident having the behavior. According to R1 they do not always bring up their concerns with the administrator or the licensee. According to interviews conducted on 06/02/23, with two (2) staff that provide R1 with 1:1 care they schedule outings with R1 but it is dependent on R1’s mood because R1 will change their mind or take a long time to get ready to go which makes it difficult for staff scheduled for the shift to take R1 on an outing. Interview with R2 on 06/02/23 states that when they ask for something staff will provide it. Interview with licensee, R2 and three (3) staff deny the allegation.

Based on interviews conducted, there is insufficient evidence to support the allegations that staff failed to meet resident's needs. Therefore, the allegation is Unsubstantiated at this time.

Allegation #2: Staff refused to assist resident. It is alleged staff refuse to assist resident#1 (R1) and the licensee does not address R1's concerns. To investigate the allegation, LPA conducted an interview with R1 on 09/07/23 for a different complaint control # 31-AS-20230831164845, R1 revealed staff are rude when R1 requests assistance. On 07/02/24, R1 stated Licensee, Asilia Wauls tries to address their concerns. Interview with three (3) staff on 06/02/23 deny the allegation, stating they do not refuse assistance to R1 and deny witnessing other staff deny providing assistance. Interview with one (1) staff revealed they have asked R1 to wait while they finish providing assistance to another resident. Interview with R2 denies staff have reused to provide assistance to them and denies witnessing staff refuse to provide assistance to other residents.

Based on interviews conducted, there is insufficient evidence to support the allegation that staff refused to assist resident. Therefore, the allegation is Unsubstantiated at this time.

Exit interview conducted, a copy of this report was signed and provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
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