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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 08/04/2025
Date Signed: 08/04/2025 04:50:21 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, CHARYFACILITY TYPE:
735
ADDRESS:43418 62ND STREET WESTTELEPHONE:
(661) 433-0625
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY:4CENSUS: 4DATE:
08/04/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Chary Hallon, Administrator and Licensee, Asalia WaulsTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff changed residents medication without consent.
INVESTIGATION FINDINGS:
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At 12:00 p.m., Licensing Program Analyst (LPA), Evelin Rios conducted unannounced subsequent visit to deliver a determination on the above allegation. LPA was granted entry by staff and met with the Administrator, Chary Hallon inside and spoke to Licensee, Asalia Wauls by telephone and explained the reason for the visit. At 4:00p.m.LPA met with the licensee.

At 12:30 p.m., LPA conducted a physical plant inspection to assure the health and safety of the residents in care.

Allegation: Staff changed residents medication without consent. It was alleged, client #1’s (C1’s) medication was changed becasue it suddenly looked different in color and size. To investigatethe the allegation, on 01/22/2025 LPAs Evelin Rios and Nadia Shahbazian conducted an initial complaint visit.
(Continue to LIC9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
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-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: 08/04/2025
NARRATIVE
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 (Continued from LIC9099)

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., LPA conducted interviews with client #1 (C1) and attempted interviews with two (02) other clients (C3 and C4) that did not respond to questioning. LPAs also interviewed three staff (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 (C1’s) physician’s report, Centrally Stored Medication Records (LIC622), Medication Administration Record (MAR), after visit paperwork for a medication refill request on 12/06/2024 and Special Incident Reports (SIRs) submitted to the Community Care Licensing (CCL). On 01/22/2025 LPAs conducted a medication review and made observations of the pills in the bottles. LPA's observation of two different PM medications revealed each bottle had one pill that appeared a different color and size then other pills in the bottle. According to staff familiar with medication administration in the facility it appears as staff poured older medication into the new refilled bottles. Based on the description on the older bottle the medication was the same. Staff immediately removed the pills that did not resemble the others and sit it aside for destruction. According to the administrator C1 had changed their insurer and medication refills were being navigated but would be refilled by initial insurer. Based on records and medication observation the client's medication was the same prescribed medication and dosage but had changed in color and size therefore the allegation is deemed Unsubstantiated at this time.

Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3