<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 01/30/2026
Date Signed: 01/30/2026 05:00:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
01/31/2025 and conducted by Evaluator Evelin Rios
COMPLAINT CONTROL NUMBER: 31-AS-20250131102020
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:
01/30/2026
UNANNOUNCEDTIME BEGAN:
02:43 PM
MET WITH:Administrator - Chary HallonTIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff physically assaulted resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Evelin Rios conducted an unannounced subsequent complaint visit to deliver a determination on the above mentioned allegation. LPA was granted entry by staff and met with the Administrator, Chary Hallon. LPA explained the reason for the visit.

Allegation: Staff physically assaulted resident. It was alleged that Staff #1 (S1) grabbed a resident, threw the resident to the ground, and restrained them similar to a wrestling hold. To investigate the allegation, LPA Rios conducted three (3) unannounced visits on 02/04/2025, 08/04/2025, and 10/06/2025. During these visits, LPA Rios completed physical plant tours to ensure the health and safety of clients in care, interviewed staff and clients, and obtained copies of records relevant to the investigation. Records reviewed and obtained included, but were not limited to, C1’s Individual Program Plan, physician’s report, facility quarterly report, Individual Support Plan, and incident report related to C1 from 1/31/25. LPA also obtained copies of Staff #1’s (S1) personnel record (LIC 500) and training documentation.
(Continue to LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
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-20250131102020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/30/2026
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
26
27
28
29
30
31
32
On 02/04/2025, LPA attempted to interview two (2) of the three (3) clients; however, Client #1 (C1) and Client #2 (C2) did not respond to the LPA’s questions due to their limited verbal communication ability. From approximately 12:50 p.m. to 2:30 p.m., LPA interviewed Client #3 (C3), eight (8) staff members, and the licensee. During the visit on 08/04/2025, from approximately 12:05 p.m. to 12:30 p.m., LPA interviewed the administrator and Client #2 (C2). On 10/06/2025 LPA Rios requested a copy of the Corrective Action (CAP) developed by North Los Angeles County Regional Center and the facility.

On initial visit LPA Rios did not observe serious injuries to C1 and was not able to determine if injuries on C1 were self inflicted or not. LPA’s interview with C3 supported the allegation stating that S1 had been rough with them as well. C1 did not provide any specific information regarding S1's treatment of C1 and C2. Interview with two (2) out of eight (8) staff corroborate the allegation. Although neither staff member reported witnessing S1 take C1 to the ground, one (1) staff member stated they had observed S1 being rough with C1, and another reported witnessing S1 press their elbows into C1’s back and antagonize clients to provoke arguments among them. Both staff members acknowledged they did not report these incidents to the administrator or licensee. One (1) stating they were never asked, and the other stating they did not realize that the restraint or hold used was inconsistent with CPI training until receiving additional training. Interview with the administrator and Licensee denied they had witnessed S1 or other staff mistreat clients and denied receiving allegations regarding S1’s treatment of C1. LPAs interview with C2 revealed they witnessed a client be brought down to the floor and held on the ground. C2 did not provide specific information about who was involved and when they witnessed the incident only that it was protect them from the client. Review of CAP revealed NLACRC interviewed a staff that witnessed S1 grab C1 by their hands and lay on C1, slapping C1's arms and head. C1. Review of S1's CPI training was up to date. C1’s IPP revealed C1 requires constant supervision during waking hours to prevent injury/harm in all settings. C1 has disruptive behaviors that interferes with social participation almost every day. LPAs review of C1’s Behavior Support Strategies in their Individual Support Plan indicates C1 should be given one step instructions. In Crisis Plan the priority would be for staff to intervene to keep C1 safe and staff should use a most-to-least prompting procedure.

Based on staff interviews and consistent statements, the allegation is Substantiated at this time.

Deficiency cited (refer to LIC9099-D) Exit interview conducted. Appeal rights provided. Copy of report provided.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 31-AS-20250131102020
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2026
Section Cited
CCR
80072(a)(3)
1
2
3
4
5
6
7
(a) ...each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature...
1
2
3
4
5
6
7
S1 no longer works in the facility. Facility has completed CAP for NLACRC as of April 2025. Administrator submitted in-service training regrading CPI and Personal Rights to LPA during today's visit. POC cleared today.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on interviews S1 was witnessed violating C1's personal rights which is an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/30/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3