197610088-10-7-2024-31-AS-EMIR-DAYUWS-20241113145714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:26:33 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
10/02/2024 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20241002113718

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:	10/07/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Chary Hallon		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Staff did not allow resident to leave the facility premises.
Staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

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On 10/07/2024 at 9:15 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility mentioned above to conduct an unannounced complaint investigation. LPA was greeted by staff and granted access. Staff #1(S1) contacted the Administrator, Chary Hallon and the Licensee Asilia “Dolly” Wauls by telephone to inform them LPA was at the facility. At approximately 10:30 a.m., LPA met with the administrator and explained the reason for the visit. An entrance interview was conducted. LPA met with the Licensee shortly after.
At 9:30 a.m. LPA conducted a tour of the facility to assure the health and safety of the clients in care.
To investigate the allegations LPA conducted interviews from 9:24 a.m. to 12:00 p.m. with the administrator, licensee, S1, Staff #2(S2), and client#1(C1). LPA attempted to interview client #2(C2) and client #3(C3). LPA obtained and reviewed copies of C1’s Medication Administration Record (MAR), Centrally Stored Medication and Destruction Record (CSMDR), Physicain's Report, Individual Program Plan (IPP), glucose record documented by staff and glucose levels recorded on glucose meter. (Continued on LIC9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

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-20241002113718

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: 10/07/2024

NARRATIVE

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At approximately 2:00 p.m. LPA interviewed staff #3(S3), client #4(C4), and attempted to interview C1’s, Service Coordinator from North Los Angeles County Regional Center (NLACRC).

Allegation #1: Staff did not allow resident to leave the facility premises. Regarding the allegation it was reported that administrator “Dolly” did not allow client#1(C1) to leave the facility on 10/02/2024. LPA's interview with C1 revealed that prior to 10/02/2024 they had to go to the emergency room because their blood sugar was high but once the nurse informed C1 they needed an IV to reduce their blood sugar level, C1 states, they refused and left. C1 states staff used that as an excuse to not allow C1 to go to the pool. C1 states they were feeling fine and preferred physical activity rather than the IV to reduce blood sugar level. LPA’s interview with three (3) staff that handle client's medication and work with C1 on a 1 to 1 basis deny the allegation. Three (3) staff stated they do not forbid clients from leaving the facility or have witnessed staff not allow clients to leave the facility. According to S1, C1 can communicate where they want to go and is driven to outings and appointments. Interview with the licensee and the administrator revealed that on 10/02/2024 they did not deny C1 the ability to leave the facility but expressed concerned about C1’s blood sugar level reading and communicated to C1 that they did not support C1’s decision to leave the facility without addressing their glucose level first. Administrator states they had explained to C1 that hospital staff had expressed disbelief that C1 was able to walk given their high glucose level. According to the administrator they had a conversation with C1’s service coordinator who informed them, C1 has the right to leave the facility if they choose to. Administrator states C1 arranged transportation with ride service company and left the facility refusing 1:1 to accompany them. Interview with S3 revealed they asked C1 if they wanted them to go with them, but C1 told them to stay behind at the facility. C1 denies S3 was allowed to go with them. Interview with C4 denies the allegation, having no issues with leaving the facility. LPA's review of C1’s medication revealed they have refused at least one daily medication for managing amount of sugar in the blood prior 10/02/2024 and after. C1 records also indicate sugar levels remain high. C1's IPP reports they are medication - noncompliance. Based on interviews and record review this allegation is deemed UNSUBSTANTIATED as C1 left the facility willingly on 10/02/2024 even when advised by a medical professional that glucose level was high.

(Continued to LIC9099-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20241002113718

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: 10/07/2024

NARRATIVE

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Allegation #2: Staff mismanaged resident's medication. Regarding the allegation it was reported client #1(C1) has run out of medication. LPA's interview with the administrator revealed C1 had a high glucose level reading on 09/30/2024 and after refusing an IV treatment from one hospital C1 went to a different hospital were they provided C1 with medication refill. Administrator and staff interviews deny C1 was out of medication but was running low. According to the administrator and S1, C1 had changed their insurance without informing staff. LPA's interview with S2, responsible with medication assistance, revealed C1 has refused medication and C1 had not run out of medication. LPA's interview with S1, revealed their was confusion with C1's doctor's appointment which did concern them about C1's medication refill but denies C1 was out of medication. LPA's interview with C1 revealed inconstancies with reason for going to the emergency room first stating it was due to glucose level and IV refusal later stating it was to refill medication order due pill shortage. LPA's interview with C4 denies having medication issues or concerns. LPA review of medication and CSMDR and MAR revealed no gaps or missing medication. C1 refuses to provide after visit summary to facility. C1 did not provide LPA with a copy of the after visit summary. Based on interviews and record review there is not enough evidence to prove that the alleged violation occurred, therefore this allegation is deemed UNSUBSTANTIATED at this time.

No deficiency cited. Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024

LIC9099 (FAS) - (06/04)

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