197610088-1-6-2026-31-AS-ERIS-DQ3VUV-20260106154521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610088
Report Date: 01/06/2026
Date Signed: 01/06/2026 04:04:59 PM

Document Has Been Signed on 01/06/2026 04:04 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TIGERTAIL ADULT HOME 4, INC.		FACILITY NUMBER:	197610088
ADMINISTRATOR/ DIRECTOR:	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:	01/06/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Chary Hallon - Administrator		TIME VISIT/ INSPECTION COMPLETED:	03:55 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 01/06/2026 at 9:10 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at this facility to conduct an unannounced Required Annual Inspection. LPA was greeted by staff who granted access. Staff called the administrator, Chary Hallon and informed her LPA was at the facility. LPA Rios signed in and observed required postings on a wall by the entry. Administrator met LPA at 11:00 a.m., and LPA explained the reason for the visit. Licensee, Asalia Wauls arrived shortly after at 11:53 a.m. At 9:25 a.m., LPA initiated a physical plant tour of the facility inside and out. This is a two story home with four (4) of five (5) bedrooms designated for clients and two (2) of three (3) bathrooms designated for clients. Common Areas: These include multiple living and dining spaces. LPA observed that areas were clean, and free of clutter. The dining and living room furniture accommodates the facility’s capacity. In the living area near the kitchen, LPA observed a television and board games available for clients use. Additionally, there is a loft on the second floor. LPA observed the loft to be clean and furnished with seating, a television, and the facility telephone for clients. Kitchen: The kitchen was observed clean. LPA was informed the refrigerator in the kitchen is currently used by Client #2 (C2) along with a smaller refrigerator that is also stored in the kitchen. LPA observed items on kitchen counters. According to staff, C2 has designated kitchen counter space. Facility stores knives, sharps, first aid kit, client's medications and facility records in a hallway closet by the downstairs bathroom. The closet was observed locked. LPA observed two (2) fire extinguishers fully charged with a serviced date of 01/17/2025. (Continue to LIC809-C) Page 1 of 3

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TIGERTAIL ADULT HOME 4, INC.	FACILITY NUMBER: 197610088
	VISIT DATE: 01/06/2026

NARRATIVE

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(Continued from LIC809) Backyard: The backyard is fenced in. No bodies of water observed. LPA observed a patio area with appropriate outdoor furniture for clients. Passageways to the exit was clear.

Laundry Room & Garage: LPA observed the laundry room was locked. Laundry room has a washer and dryer that was observed operational. LPA observed detergents and cleaning products stored in laundry room. The attached garage is accessed through the laundry room. In the garage LPA observed a second refrigerator and a deep freezer for the facility. Emergency supply of food and water are stored in the garage. LPA observed items belonging to C2 stored in the garage. LPA observed that the kitchen pantry, garage refrigerator, and deep freezer contained at least a seven day supply of non-perishable food and a two day supply of perishable food items.

Bedrooms: LPA observed client bedrooms to be properly furnished. While touring bedrooms LPA spoke with C2 regarding their rooms cleanliness. According to staff and the administrator the facility has taken action by attempting to work with C2 regarding food brought into their bedroom. According to C2 they will no longer store food in their room. LPA observed rice cakes in a bag on top of a drawer in C2's bedroom. Administrator provided an exterminator receipt for services provided and ongoing maintenance related to C2's bedroom and observation of pest by staff.

Bathroom: The bathrooms were properly supplied with hand soap, paper towels and toilet paper. Hot water temperature was taken in both bathrooms and measured between 106 degrees Fahrenheit and 105.8 degrees Fahrenheit, within regulation.

Smoke / Carbon Monoxide Detectors: LPA observed smoke/carbon monoxide detectors through out the facility. Staff tested the detectors at 10:13 a.m., and they were observed operational.

(Continue to LIC809-C) Page 2 of 3

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TIGERTAIL ADULT HOME 4, INC.	FACILITY NUMBER: 197610088
	VISIT DATE: 01/06/2026

NARRATIVE

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(Continued from LIC809-C) Staff/Client Records: At approximately 10:10 a.m. LPA conducted record reviews for six (6) out of twelve (12) staff files to ensure compliance with licensing forms. Shortly after, LPA reviewed all four (4) client records to ensure they were complete and up to date. LPA reviewed incident report regarding Client #1 (C1) having a fall at the facility on 01/03/2026 and obtaining stiches on their right eyebrow. According to records the client has been experiencing balance issues and is being seen by a specialist. A new medical assessment has been done and facility is waiting for updated LIC602. LPA advised that the facility has a fire clearance for four (4) ambulatory clients and depending on ambulatory status from future procedures or outcomes a plan should be developed with C2 and their interdisciplinary team responsible for C2's care. Administrator will email LIC602 to LPA once received.

Medications: At approximately 2:32 p.m. LPA reviewed Centrally Stored Medication Destruction Records and medication for proper documentation. Centrally Stored Medication Records are automatically filled by pharmacists for three (3) out of four (4) clients. Facility also maintains Medical Administration Records (MAR).

LPA reviewed facility's surety bond and Personnel Report (LIC 500) to ensure coverage.

No deficiencies cited on todays visit. Exit interview conducted. Copy of report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/06/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026

LIC809 (FAS) - (06/04)

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