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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:38:35 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/19/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20220819113032
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:
09/22/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Asilia Wauls - Licensee TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility serves food of low quality.
Licensee is not meeting the dietary needs of client.
Licensee did not safe guard clients personal belongings.
INVESTIGATION FINDINGS:
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On 9/22/2022 at 10:30 a.m. Licensing Program Analysts Melissa Ruiz and Angela Panushkina (LPAs) arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPAs were greeted by staff and LPAs later met with Licensee, Asilia Wauls. An entrance interview was conducted and the purpose of the visit was explained.

Facility serves food of low quality.
Licensee is not meeting the dietary needs of client.

During the initial visit on 8/29/22, LPA Ruiz observed the refrigerators to have a low supply of food. Interviews with two (2) staff and the licensee revealed that grocery shopping is done once every two weeks or as needed. During todays visit, LPAs conducted a walk-through of the kitchen, specifically two refrigerators and one freezer.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
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 4
Control Number 31-AS-20220819113032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
VISIT DATE: 09/22/2022
NARRATIVE
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LPAs observed an insufficient amount of perishable foods. Additionally, LPAs observed very limited quantity of nutritious food. Lastly, LPAs collected food menus from various dates, based on the food menus, facility is not providing balanced or nutritious meals.

Licensee did not safe guard clients personal belongings.

Based on interviews conducted with the Licensee and C1 revealed that C1 moved into this facility April 2022. An interview with C1 stated that upon their admission, they brought a few items such as clothes, phone, and chair.To investigate this allegation, LPAs requested LIC621 (Client/Resident Personal Property and Valuables Form), and LPAs observed that the form was not signed and or completed as of the admission date for C1.

Based on observations and interviews conducted, the allegations mentioned above are substantiated. Deficiencies issued per CA Code of Regulation, Title 22. Report signed and delivered. Exit interview conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 31-AS-20220819113032
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited
CCR
80076(a)(1)
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply:
(1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients. Each meal shall meet at least 1/3 of the servings recommended in the USDA Basic Food Group Plan - Daily Food Guide for the age group served. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Licensee agrees to purchase food to meet the requirements necessary within section 80076(a)(1). A copy of receipt and photographs shall be submitted by the POC due date.
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This requirement is not met as evidenced by:
Based on observations, interviews and document review, the Licensee did not ensure that clients are being provided with quality/quantity food service. This poses a potential health and safety or personal rights risk to clients in care.
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Type B
09/29/2022
Section Cited
CCR
80026(h)
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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents. (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care, including, but not limited to the following: This requirement is not met as evidenced by:
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The Licensee has agreed to complete the LIC621 form for all clients in care. Proof of completion shall be submitted by the POC due date.
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Based on record review and interviews, the licensee did not ensure that accurate records such as the LIC621 was completed and or signed by C1. This poses a potential health and safety or personal rights risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/19/2022 and conducted by Evaluator Melissa Ruiz
COMPLAINT CONTROL NUMBER: 31-AS-20220819113032

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:
09/22/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Asilia Wauls - Licensee TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff speaks inappropriately to client.
INVESTIGATION FINDINGS:
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To investigation this allegation, LPAs conducted interviews with the Licensee, Administrator and four (4) staff members. One staff interview was conducted on a seperate complaint visit on 7/15/2022. Interviews with all staff revealed that no staff speak inappropriately to any client, specifically C1. Interviews with the Licensee, Administrator and two (2) staff stated that C1 speak to staff members in a derogatory manner when C1 does not get their way or does not feel their best. An interview with another client (C2) revealed that they have never witnessed any staff speak to clients in an inappropriate manner. Based on interviews conducted, there is insufficient information to prove that the allegation may have happened, therefore the allegation "staff speaks inappropriately to client" is unsubstantiated. Exit interview conducted, report signed and delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4