197610088-7-15-2025-31-AS-MGFS-DU7SJJ-20260518135509

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 07/15/2025
Date Signed: 07/15/2025 03:28:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/14/2025 and conducted by Evaluator Evelin Rios

COMPLAINT CONTROL NUMBER: 31-AS-20250114101006

FACILITY NAME:	TIGERTAIL ADULT HOME 4, INC.		FACILITY NUMBER:	197610088
ADMINISTRATOR:	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:	07/15/2025
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Maria Reyes (DSP)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff confiscated resident's personal item.
Staff threw away resident's personal food.

INVESTIGATION FINDINGS:

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At 1:45 p.m., Licensing Program Analyst (LPA), Evelin Rios conducted unannounced subsequent visit to deliver determinations on the above allegations. LPA met with Direct Support Staff (DSP), Maria Reyes and spoke to Licensee Asalia Wauls by telephone and explained the reason for the visit. Licensee designated staff to sign today's report.
At 2:07 p.m., LPA conducted a physical plant tour, to ensure the health and safety of the clients in care.
To investigate the above allegations LPAs Evelin Rios and Nadia Shahbazian conducted an initial complaint visit on 01/22/2025. On the initial visit at 9:46 a.m., LPAs conducted a physical plant inspection. From 9:46 a.m., to 2:00 p.m., LPAs conducted interviews with three (03) clients of which two (02) did not respond to questioning. LPAs also interviewed three (03) staff and the Licensee Asalia Wauls. LPA requested copies of relevant documents pertaining to the investigation, including, but not limited to, the following: resident #1’s (R1’s) physician’s report, admission agreement, Individual Program Plans (IPP) from 11/15/2019 and 1/11/2023, quarterly progress reports, and Special Incident Reports (SIRs) submitted to the Community Care Licensing (CCL). (Continue to LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250114101006

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/15/2025

NARRATIVE

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(Continued form LIC9099) Allegation: Staff confiscated resident's personal item. Regarding the allegation it was reported that staff confiscated client #1’s (C1’s) special scissors. LPAs interview with C1 revealed they purchased arts and craft scissors and kept the scissors on them and in their bedroom. When they would go missing R1 would purchase more scissors. R1 suspects staff took three (03) sets of scissors and stored them in a locked closet on the ground level. LPA’s interview three (03) out of three (03) staff confirmed scissors were confiscated for clients’ safety. According to one (01) staff, C1 was informed staff locked the scissors and if they asked for them, they could use scissors with supervision. Interview with C1’s 1:1, staff #3 (S3) also confirmed scissors were taken away and a discussion regarding the scissors was had with C1. LPA observed S2 remove four (04) craft scissors and one (01) regular scissor from a closet that is maintained locked. LPA’s review of facility‘s Sharp Safe Policy, states not verbatim, items such as scissors will be locked up and if client requisites safety skills they can use them with staff supervision. Based on interviews and review of the facility program although the items were confiscated the facility’s safety policy regarding sharps the items had to be removed and made inaccessible to clients. Therefore, this allegation is deemed Unsubstantiated at this time.

Allegation: Staff threw away resident's personal food. Regarding the allegation it was reported that staff constantly throw away R1’s food. LPA’s interview with R1 on 01/22/2025 affirmed the allegation stating cream cheese and toast they purchased was gone. LPA inquired about the freshness of the food C1 reported they freeze food if they are not able to finish it before expiration date and will eat items that are expiring first. During tour of C1’s room LPA observed food on top of C1’s furniture. Interview with three (03) out of three (03) staff revealed the food they throw out is rotten. According to S1 during a visit conducted by North Los Angeles County Regional Center representative they informed staff expired and spoiled food must be thrown out as it is a health and safety concern for C1. According to one (01) staff, C1 becomes aggressive when staff attempt to throw out spoiled food so they have to wait for R1 to be away and take pictures of the food before staff is instructed to throw it out. Interview with the Licensee corroborates staff are instructed to throw out old food and the rule is to let C1 know the food was thrown out by staff. LPA’s review of C1’s quarterly progress report conducted by the facility documents a history of issues relating to spoiled food. Based on LPA’s observation, interview and review of records the allegation is deemed Unsubstantiated at this time.

No deficiencies cited. Exit interview conducted. Copy of report signed and provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 07/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2025

LIC9099 (FAS) - (06/04)

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