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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610088
Report Date: 01/29/2024
Date Signed: 01/29/2024 04:13:04 PM

Document Has Been Signed on 01/29/2024 04:13 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:
01/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Chary HallonTIME COMPLETED:
04:15 PM
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On 01/29/2024 at 10:15 a.m. Licensing Program Analysts (LPA) Evelin Rios arrived at this facility to conduct a Required Annual Inspection. LPA was greeted by the house manager Maria Reyes who granted access. Maria called administrator Chary Hallon and informed her the reason for the visit. Chary met with LPA at 11:28 a.m. LPA Rios explained the reason for the visit. LPA Rios reviewed the required postings on a wall by the entry. The inspection tool was used to complete the visit. Licensee Asalia Wauls arrived at 11:42 a.m.

At 10:16 a.m. LPA along with Maria began a physical plant tour of the facility and the following was observed by LPA:
Common Areas: These include the living areas, dining areas and the loft. LPA observed dining, living and loft areas clean and clear of clutter with furniture in good repair. Dining and living room furniture sits the capacity of the facility.

Kitchen: LPA observed a seven day supply of non-perishable food and a two day supply of perishable foods; properly stored. Facility stores the knives, sharps, first aid kit, emergency supply of food and water, client's medications and facility records in a closet by the kitchen. LPA observed closet locked. LPA observed two (2) fire extinguishers one (1) is located by the kitchen and the second is upstairs in a hallway fully charged with a serviced date of 01/23/2024.

Bedrooms: There are four (4) client bedrooms for single use. LPA observed bedrooms to be properly furnished with a bed, linens, night stand, a chair, drawers, closet, and adequate lighting. While touring bedroom for client #1 (C1), pest control arrived. LPA introduced themselves and asked staff what service was being provided. According to Licensee and administrator staff needed to clean C1's bedroom due to the condition it had been. Staff that cleaned room noticed what appeared to be a rodent's nest and droppings.

(Continue on LIC809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 01/29/2024
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Staff reported this information to the administrator and they called pest control same day. Pest control company scheduled an appointment to see the room on 01/26/2024 and gave facility an estimate for services. Pest control retuned to the facility today and performed treatment and schedule continued visits for monitoring. Due to the ongoing situation with C1, documented by facility and the department, LPA determined the facility acted immediately to address the incident. It has been document by facility that C1 is known to bring items like boxes from the outside which may have carried in a rodent.

Bathroom: There are two (2) client bathrooms one (1) is located upstairs and the second bathroom is downstairs. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. Hot water temperature was taken in both bathrooms at approximately 2:45 p.m. and measured upstairs 112.9 degrees Fahrenheit and 113.9 degrees Fahrenheit downstairs.

Laundry Room & Garage: LPA observed the laundry room locked. Laundry room has a washer and dryer. LPA observed detergents and cleaning products in laundry room. The garage is attached to the facility. Laundry room that is maintained locked leads to the garage and LPA observed additional storage for the facility and personal belongings for C1. LPA noted an odor being omitted by C1's personal items. According to Maria, staff had recently cleaned C1's room and the items placed in the garage needed to be clean or removed from the facility due to a risk to C1's and other client's health.

Backyard: LPA observed a patio area with appropriate outdoor furniture for clients. The side gate leading from the backyard to the front yard was closed but not locked.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by the a staff at 10:48 a.m. and were observed operational.

Staff/Client Interview: At 11:20 a.m. LPA conducted record reviews for six (6) out of thirteen (13) staff files to insure compliance with licensing forms. At approximately 12:40 p.m. four (4) out four (4) client records were reviewed to insure compliance.

Medications: At approximately 2:21 p.m. LPA with administrator reviewed Centrally Stored Medication Destruction Records for proper documentation. Medication records are automatically filled by pharmacists for three (3) out of four (4) clients. Facility also maintains Medical Administration Records (MAR).



No deficiency cited on todays visit. Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2024
LIC809 (FAS) - (06/04)
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