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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610088
Report Date: 04/27/2023
Date Signed: 04/27/2023 02:22:59 PM

Document Has Been Signed on 04/27/2023 02:22 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: DATE:
04/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Ramos (House Manager)TIME COMPLETED:
02:30 PM
NARRATIVE
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On 04/27/2023 Licensing Program Analyst (LPA) Evelin Rios conducted an announced Case Management - Incident visit in conjunction with complaint control # 31-AS-20230420130932. LPA informed Licensee and Administrator the purpose of this visit. LPA received a Special Incident Report (SIR) on 04/27/2023. Facility self reported an incident that was reported to them on 4/26/23. According to SIR staff #1 (S1) witnessed as stated on SIR "physical abuse" done to Client #1 (C1) by staff #2 (S2) on 04/21/2023. According to S1, S2 hit C1 on their back with a mop stick. S1 reported to Staff #3 (S3) who then advised S1 to report it to administrative staff office to report what S1 had witnessed. Administrative staff immediately decided to suspend S2 and have them removed from all Tigertail Adult Home facilities while this allegation is being investigated. As a result, an SOC341 report was submitted to Adult Protective Services on 4/27/23 to report the possible physical abuse to C1. The Palmdale Sheriff Department was also contacted on 4/26/23 to request a formal investigation on this subject. Staff has been notified not to allow S2 into any Tigertail Adult Facilities.

LPA conducted a physical plant tour to ensure the health and safety of the clients in care. LPA did not observe any health and safety issues or concerns at the facility. From 10:20 a.m. to 1:50 p.m. LPA interviewed house manger, Licensee, Administrator and gathered and reviewed records relevant to the SIR. LPA review of records determined S1 was not associated to this facility. According to Licensee and Administrator they believed S1 was fingerprinted, background cleared and was associated to this facility. Administrator stated they will immediately associate S1 through Guardian if they are not associated. LPA reviewed Facility Personnel Report Summary with Administrator and determined S1's name did not appear on the list of associated personnel. Further information is required to determine possible deficiencies.

Copy of report provided. Exit interview conducted.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/27/2023
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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Document Has Been Signed on 04/27/2023 02:22 PM - It Cannot Be Edited


Created By: Evelin Rios On 04/27/2023 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited
CCR
80091(f)(1)

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(f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another... state licensed facility by providing the following documents to the Department:(1)A signed Criminal Background Clearance Transfer Request, LIC 9182 (Rev. 4/02).This requirement is not met as evidenced by:
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Licensee shall submit evidence of transfer request or completion of transfer/ association of staff #1 to this facility. A copy of the receipt shall be provided to CCL/LPA by POC due date.
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Based document review, the Licensee did not ensure that S1 was associated to the facility. This poses an immediate 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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023


LIC809 (FAS) - (06/04)
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