<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197610088
Report Date:
03/27/2023
Date Signed:
03/27/2023 05:14:20 PM
Document Has Been Signed on
03/27/2023 05:14 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:
4
DATE:
03/27/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:00 AM
MET WITH:
Maria Ramos
TIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03/27/2023 Licensing Program Analyst (LPA) Evelin Rios conducted a case-management visit in conjunction with complaint control # 31 31-AS-20230321145951. During physical plant tour LPA observed resident #1's (R1) bedroom with clutter and items appeared to be knocked over on the floor. LPA also observed crumbs on the floor. According to Maria staff have tried multiple time to assist and help R1 clean room. R1 according to Maria refuses to allow staff to enter room to clean and throw out expired food. R1 is offered to make a cleaning schedule so staff may assist in cleaning bedroom and R1 refuses.
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Evelin Rios
LICENSING EVALUATOR SIGNATURE
:
DATE:
03/27/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
03/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1