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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610088
Report Date: 01/13/2025
Date Signed: 01/13/2025 03:51:01 PM

Document Has Been Signed on 01/13/2025 03:51 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/
DIRECTOR:		HALLON, CHARYFACILITY TYPE:
735
ADDRESS:43418 62ND STREET WESTTELEPHONE:
(661) 433-0625
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Chary Hallon (Administrator)TIME VISIT/
INSPECTION COMPLETED:
04:05 PM
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On 01/13/2025 at 9:25 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at this facility to conduct a unannounced Required Annual Inspection. LPA was greeted by staff #1 (S1) who granted access. S1 called administrator Chary Hallon and informed her LPA was at the facility. LPA Rios signed in and reviewed the appropriate postings on a wall by the entry. The inspection tool was used to complete this visit. Chary met with LPA at 11:00 a.m., LPA Rios explained the reason for the visit. Licensee Asalia Wauls arrived at 12:40 p.m.

At 9:33 a.m., LPA along with S1 began a physical plant tour of the facility inside and out 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. LPA observed televisions and board games for clients to use. LPA observed a fireplace that is not in use.

Kitchen: LPA observed a seven day supply of non-perishable food and a two day supply of perishable foods; properly stored. LPA observed pots and pans and sufficient amount of tableware. Facility stores the knives, sharps, first aid kit, emergency supply of food and water, client's medications and facility records in a closet that is maintained locked. LPA observed closet locked. LPA observed two (2) fire extinguishers 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 bedrooms LPA met with client #1 (C1), who locked their bedroom door. According to S1, staff were able to clean C1's bedroom on 12/26/24 but C1 has documented issues with keeping their bedroom clean. (Continue to LIC809)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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: 01/13/2025
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(Continued from LIC809) C1 allowed LPA to view bedroom from the doorway. LPA observed the door not able to open all the way. LPA observed items stacked on furniture surfaces.

Bathroom: There are two (2) client bathrooms. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. Hot water temperature was taken in both bathrooms at approximately 12:43 p.m. and measured 116.8 degrees Fahrenheit in the upstairs bathroom and 118.3 degrees Fahrenheit in the downstairs bathroom, within regulation.

Laundry Room & Garage: LPA observed the laundry room locked. Laundry room has a washer and dryer that was observed operational. LPA observed detergents and cleaning products in laundry room. The garage is attached to the facility. In the garage LPA observed a second refrigerator and a deep freezer for the facility.


Backyard: LPA observed a patio area with appropriate outdoor furniture for clients.

Smoke and Carbon Monoxide Detectors: LPA observed a carbon monoxide detector that was tested by another staff and observed operational. LPA observed smoke detectors through out the facility that are connected to each other. Staff tested the smoke detectors at 10:14 a.m. and were observed operational.

Staff/Client Records: At 11:15 a.m., four (4) out four (4) client records were reviewed to insure compliance with licensing forms. At approximately 12:40 p.m. LPA conducted record reviews for five (5) out of ten (10) staff files to insure compliance with licensing forms.

Medications: At approximately 1:20 p.m. LPA with administrator reviewed Centrally Stored Medication Destruction Records and medication 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).



LPA reviewed the facility's Evacuation Plan (LIC610D), fire and earthquake drills, Infection Control Plan and evacuation sketch. LPA requested an updated facility sketch and LIC200 for the bedroom on the ground level. LPA and administrator discussed facility's emergency intervention plan and C1's crisis plan. C1 had given LPA permission to discuss their concern with administrator in regards to physical restraint and crisis intervention techniques (CPI) training.

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: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
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