197610088-8-21-2024-31-AS-NGID-D9MSA6-20241001134147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 08/21/2024
Date Signed: 08/21/2024 12:51:08 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
12/19/2023 and conducted by Evaluator Lorena Casillas

COMPLAINT CONTROL NUMBER: 31-AS-20231219095237

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:	08/21/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Chary Hallon		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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Staff abused resident.
Staff made inappropriate comments to residents.

INVESTIGATION FINDINGS:

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On 08/21/2024 at 09:30 am Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced subsequent visit to this facility to investigate the above stated allegations. LPA was greeted by staff and was granted access to the facility. Staff contacted the Administrator and LPA explained the reason for the visit. Administrator Chary Hallon arrived shortly after.

On 12/19/2023, the Woodland Hills South Adult and Senior Care Regional Office received a complaint regarding the allegations mentioned above.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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-20231219095237

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TIGERTAIL ADULT HOME 4, INC.	FACILITY NUMBER: 197610088
	VISIT DATE: 08/21/2024

NARRATIVE

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On 12/20/2023, LPA Evelin Rios initiated the complaint visit. LPA Rios conducted a tour of the facility and obtained emailed copies of pertinent information. LPA Rios also conducted interviews with the Administrator, two (2) staff and two (2) out of four (4) clients who were present at the facility. LPA Casillas reviewed documents collected by LPA Rios. LPA Casillas also reviewed interviews conducted by LPA Rios.

At 09:45 AM LPA Casillas conducted a physical plant tour. During the investigation, interviews and record reviews were conducted from 10:00 am to 12:30 pm. LPA requested copies of updated resident roster, updated LIC 500, Administrator Certificate and bond certificate, Administrator will email copies to LPA. LPA requested copies of IPP plans for all clients, behavior logs and any other information pertaining to the investigation, Administrator will email copies to LPA. There were three (3) clients present and one (1) client out in the community. LPA Casillas conducted interviews with Administrator, four (4) staff present and one (1) client out of three (3) that were able to communicate with LPA and were present at the facility at the time of the visit.

Allegation #1 Staff abused resident.

It is alleged that staff abused residents. Regarding this allegation it is reported that Staff #1 (S1) was seen in Client #1’s (C1) room while C1 was undressed and crying. It is reported that although no visible injuries were noticed, that C1 was crying more than usual. Interviews with Administrator and four (4) staff state that C1 will cry as part of C1’s behavior when C1 does not want to shower or sometimes just randomly. C1 will also self-harm and undress needing to continuously be redirected, this will also at times trigger a bout of crying. According to Administrator and four (4) staff, C1 needs assistance with daily chores that include showers and will often undress and need to be redressed. Interviews with Client #2 (C2) revealed that C1 always cries even when nothing seems to be wrong. Furthermore, interview with C2 revealed that S1 takes good care of C1 and C2 is not sure why this allegation was made. LPA reviewed C1’s documents and it was discovered that C1 has disruptive behaviors on a daily basis to include crying and attempts to self harm. Therefore, based on interviews, observations and record reviews this allegation is deemed Unsubstantiated at this time.

Continued on LIC9099-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20231219095237

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TIGERTAIL ADULT HOME 4, INC.	FACILITY NUMBER: 197610088
	VISIT DATE: 08/21/2024

NARRATIVE

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Allegation #2 Staff made inappropriate comments to residents.

It is alleged that staff made inappropriate comments to residents. Regarding this allegation it is reported that Staff #2 (S2) addresses clients with inappropriate comments and does not address clients by their name, instead will call clients “Grandpa”. Interview with Administrator revealed that none of their staff address any of the clients in a demeaning or derogatory manner. Per Administrator, all clients are treated with dignity and respect. Interview with four (4) staff present, deny this allegation stating that they have never witnessed S2 address any of the clients in any manner other than respectfully. Furthermore, interviews with staff revealed that it is in fact Client #2 (C2) that verbally threatens and disrespect's staff constantly using derogatory language, all four (4) staff indicate that they have been subject to C2’s derogatory language and threatening behavior. Interview with C2 also denied this allegation stating that S2 doesn’t bother C2. Interview with C2 revealed that C2 does not have any issues with S2 and have not had any concerns about the way that S2 speaks to any of the clients. C2 denies this allegation and states that C2 never said anything to imply that S2 spoke to clients inappropriately. Therefore, based on interviews, record reviews and observations this allegation is deemed Unsubstantiated at this time.

No citations issued. Exit interview conducted. Copy of report provided to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC9099 (FAS) - (06/04)

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