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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610088
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:39:56 PM

Document Has Been Signed on 09/07/2023 03:39 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, CHARYFACILITY TYPE:
735
ADDRESS:43418 62ND STREET WESTTELEPHONE:
(661) 433-0625
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
09/07/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Chary HallonTIME COMPLETED:
03:00 PM
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On 09/07/2023 Licensing Program Analysts (LPA) Evelin Rios conducted an announced Case Management Incident visit to follow up with the facility about the Special Incident Report (SIR) received by CCL on 04/26/2023 and case management visit from 04/27/2023. Since alleged allegation of "physical abuse" as stated on SIR facility removed staff member from the schedule and staff member has not returned to work for any Tigertail Adult Home facilities. Facility has not received a status update from the Palmdale Sheriff Department about the police report filed against said staff. LPA interviewed alleged staff mentioned in SIR and witness statement and they deny the allegation. Due to no corroborating witness, no visible injuries, and no history of similar allegations against staff in question there was not enough evidence to prove the alleged violation did or did not occur.

No deficiencies cited. Copy of report provided. Exit interview conducted.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/07/2023
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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