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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610088
Report Date: 01/27/2022
Date Signed: 01/28/2022 01:44:06 PM

Document Has Been Signed on 01/28/2022 01:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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: DATE:
01/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Chary HallonTIME COMPLETED:
01:50 PM
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At 1:05 p.m., Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection visit to the facility mentioned above. LPA met with the Administrator, Chary Hallon who granted access to home. This is a five bedroom, three bathroom facility.

Infection Control: LPA reviewed facility mitigation plan (submitted on 1/23/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA noticed some COVID-19 signs posted outside the facility. Additional COVID-19 signage was posted by the main entrance. LPA observed a designated infection control station that consisted of a visitors log and hand sanitizer.

The Administrator stated that the facility has never had clients in care but wishes to remain open for future clients. An exit interview was conducted and copy of this report was signed given to Chary Hallon, Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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