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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 10/19/2022
Date Signed: 10/19/2022 01:02:53 PM

Unsubstantiated


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
10/10/2022 and conducted by Evaluator Melissa Ruiz
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221010120714
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:
10/19/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Asilia Wauls & Chary HallonTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff are making inappropriate comments about resident to other residents.
Staff are not allowing residents to socialize with each other.
INVESTIGATION FINDINGS:
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On 10/19/2022, Licensing Program Analyst Melissa Ruiz (LPA) arrived at the facility to conduct an unannounced complaint visit. Upon arrival, LPA was greeted by staff and LPA later met with Licensee, Asilia Wauls and Administrator Chary Hallon.

Allegation#1 - Staff are making inappropriate comments about resident to other residents.

To investigate this allegation, interviews were conducted with the Licensee, two (2) staff members and two (2) out of four (4) clients. Interviews conducted with two (2) staff members revealed that they have never made inappropriate comments to clients about other clients, or witnessed any staff make inappropriate comments about clients to other clients. Two clients (C1 & C2) stated no staff have made inappropriate comments to them about other clients. An interview with the licensee revealed that to their knowledge, no staffing has made inappropriate comments about clients to other clients. Based on interviews conducted, this allegation is unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022
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 2
Control Number 31-AS-20221010120714
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
VISIT DATE: 10/19/2022
NARRATIVE
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Allegation#2 - Staff are not allowing residents to socialize with each other.

To investigate this allegation, interviews were conducted with the Licensee, the Administrator, two (2) staff members and two (2) out of four (4) clients. LPA interviewed C2 at 11:25 a.m., and C2 revealed that C1 periodically tries to talk and engage in multiple conversations with C2 that make them uncomfortable. C2 stated that sometimes, C2 does not want to talk and requests space from C1. Additionally, C2 stated that staff do allow clients to talk to one another, but C2 directed staff to instruct C1 to give C2 their space. An interview with C2 revealed that for the most part, clients can socialize with other clients, if they widh. Interviews with two (2) staff revealed that they allow clients to socialize, but lately they have been trying to separate C1 and C2 because C2 has voiced their wish for privacy. Interviews with the Licensee and the Administrator also reveal they have been informed of C2’s wishes and the do their best to allow clients to socialize among each other.

Based on interviews conducted, this allegation is unsubstantiated at this time. No deficiencies issued at this time. Report signed and delivered. Exit interview.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2