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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 09/22/2022
Date Signed: 09/22/2022 03:36:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/01/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20220601123928
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:
09/22/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Asilia Wauls, Licensee TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff are not safeguarding a client's personal items
INVESTIGATION FINDINGS:
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At 10:30 a.m. Licensing Program Analysts (LPAs) Angela Panushkina and Melissa Ruiz arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPAs were greeted by staff and later met with Licensee, Asilia Wauls. LPA explained the reason for the visit.

It was alleged that staff are not safeguarding a client's personal items. To investigate this allegation, interviews were conducted with the Licensee, Client #1 (C1). Interview with C1 revealed that when they moved to this facility in April 2022, they brought few clothes and a chair with them. Interview with the Licensee revealed that C1 did not bring/have any personal belongings during their admission to this facility. LPAs requested form LIC621 - (CLIENT/RESIDENT PERSONAL PROPERTY AND VALUABLES). Document review revealed that LIC621 was not signed and/or completed by C1 as of admission date. Based on interviews, document reviews and LPAs observation this allegation is Substantiated.

An exit interview conducted, appeal rights explained and a copy of this report provided to the Licensee.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 31-AS-20220601123928
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/29/2022
Section Cited
CCR
80070(b)(14)
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80070(b)(14) Client Records
(b) Each record must contain information including, but not limited, to the following: (14)...personal property and valuable entrusted as specified...

This requirement is not met as evidenced by:
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Licensee will ensure that all client records are complete, dated and signed. Licensee agreed to submit LIC621 for frour (4) clients to LPA by POC date.
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Based on interviews and record review, the licensee did not comply with the section cited above by failing to ensure C1's property valuables were registered as of their admission date, which poses a potential health, safety to persons 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.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/01/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20220601123928

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:
09/22/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Asilia Wauls, Licensee TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff made inappropriate comments towards a client
INVESTIGATION FINDINGS:
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5
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At 10:30 a.m. Licensing Program Analysts (LPAs) Angela Panushkina and Melissa Ruiz arrived at the facility to conduct an unannounced subsequent complaint visit. Upon arrival, LPAs were greeted by staff and later met with Licensee, Asilia Wauls. LPA explained the reason for the visit.

It was alleged that Staff made inappropriate comments towards a client. To investigate this allegation, interviews were conducted with the Licensee, three (3) out of three (3) staff and Client #1 (C1). Interviews with all staff revealed that no staff speak inappropriately to any client, specifically C1. Interviews with the Licensee, three (3) ouf of three (3) staff stated that C1 speak to staff members in a derogatory manner when C1 does not get their way or does not feel their best. An interview with another client (C2) revealed that they have never witnessed any staff speak to clients in an inappropriate manner. Based on interviews conducted, there is insufficient information to prove that the allegation may have happened, therefore the allegation mentioned above is unsubstantiated.
Exit interview conducted, report signed and delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3