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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610088
Report Date:
01/04/2023
Date Signed:
01/04/2023 12:56:15 PM
Document Has Been Signed on
01/04/2023 12:56 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
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
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:
3
DATE:
01/04/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Chary Hallon
TIME COMPLETED:
01:00 PM
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On 01/04/2022 at 11:00 a.m. Licensing Program Analysts (LPAs) Evelin Rios and Melissa Ruiz arrived at the home in order to conduct a Required Annual and infection control inspection. LPAs were greeted by Staff #1 (S1) and Staff #2 (S2) who were wearing masks and granted access. S1 called administrator Chary Hallon and informed her the reason for our visit. Chary met us shortly after. LPA Rios explained the reason for the visit. LPA Rios reviewed the Mitigation Plan approved 04/20/2021. The inspection tool was used to complete the visit.
At 11:10 a.m. LPA began a physical plant tour of the facility and the following was observed:
Infection Control:
Staff
asked LPAs to sign in the visitor log upon entry. The LPAs had their temperature taken and all covid-19 questions asked. Two (2) out of the three (3) residents were out during the visit. LPA observed dual smoke and carbon monoxide detectors through out the facility. Smoke and carbon detectors were tested at 12:38 p.m. and were observed to function properly. The fire extinguisher was observed in the kitchen and appeared to be fully charged with a purchase date of 04/20/2022. LPA observed hand washing signs at all sinks in the the kitchen and bathrooms. LPA observed trash bins with tight fitting lids to prevent cross contamination. S2 stated facility has a 30 day supply of PPE. There are five (5)
bedrooms
four (4) of which are for client use. All client bedrooms were well lit and had appropriate furniture. There are three (3)
bathrooms
one (1) of which is located in a client bedroom for private use. At 12:30 p.m. water temperature was tested at 115 degrees Fahrenheit. LPA observed C1's bedroom and bathroom to be cluttered with C1's personal belongings. S1 stated they have been working with C1 to organize his room but he refuses to throw anything away.
No deficiencies were observed during todays visit and the facility is currently following their infection control plan. Exit interview conducted and report issued.
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Evelin Rios
LICENSING EVALUATOR SIGNATURE
:
DATE:
01/04/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/04/2023
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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