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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 08/28/2024
Date Signed: 08/28/2024 11:05:59 AM

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
01/22/2024 and conducted by Evaluator Perchui Khurshudyan
COMPLAINT CONTROL NUMBER: 31-AS-20240122094555
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:
08/28/2024
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria Reyes, House ManagerTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff did not secure residents personal belongings.
Staff does not ensure resident is spoken to in an appropriate manner.
INVESTIGATION FINDINGS:
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On 8/28/24 at 9:45am Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan Angela Panushkina arrived at the facility to conduct an unannounced subsequent complaint visit. LPAs were greeted by the House Manager, Maria Ramos, who granted access. Administrator was contacted and LPAs explained the reason for the visit.

During the initial visit conducted on 01/29/24 by LPA Rios, interviews were made with one (1) client, two (2) staff, Administrator and Licensee Asalia Wauls. LPA reviewed and obtained documents relevant to the investigation.

During today’s visit LPAs conducted an additional interview with the Administrator, House Manager, one (1) out of four (4) clients, who were able to communicate.
Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
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 2
Control Number 31-AS-20240122094555
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: 08/28/2024
NARRATIVE
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Allegation: Staff did not secure residents personal belongings.

It was alleged that S1 went into R1’s room on 01/19/24 and R1’s discovered his/her bathrobe went missing on 01/20/24. To investigate this allegation, LPAs conducted an interview with the Administrator and a House Manager and were informed that no S1 (by the name provided) ever worked at this facility. LPAs were also informed that due to R1’s lifestyle, R1 always misplaces personal belongings and has a hard time finding them. During the physical plant tour, LPAs observed R1’s room was very cluttered. Interview with one (1) out of four (4) clients, who were able to communicate did not express any concerns regarding the above allegation. Based on interviews and observation, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff does not ensure resident is spoken to in an appropriate manner.

It was alleged that S1 spoke inappropriately with the client. To investigate this allegation, LPAs conducted an interview with the Administrator and a House Manager and were informed that no S1 (by the name provided) ever worked at this facility. Interview with one (1) out of four (4) clients confirmed that no S1 ever worked here. Moreover, LPAs were informed that all staff members treat clients with dignity and respect and always speak with clients in a professional manner. Based on interviews gathered during the initial and today’s visit, this allegation is deemed Unsubstantiated at this time.


No deficiency cited. Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2