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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 01/04/2023
Date Signed: 01/04/2023 02:18:27 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
12/29/2022 and conducted by Evaluator Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221229091452
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:
01/04/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Chary HallonTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not ensure clients have planned activities at the facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 11:00 a.m. Licensing Program Analysts (LPAs) Evelin Rios and Melissa Ruiz arrived at the facility to conduct an unannounced complaint investigation. Upon arrival, LPA was greeted by staff #1 (S1) and allowed entrance to the facility. LPA later met with Licensee Dolly and Administrator Chary an entrance interview was conducted, the purpose of the visit was explained.
Based on interviews conducted on today’s visit with S1 and the Licensee it was revealed that C1 has started to create their own activity schedule as of 01/02/2022. Licensee stated the facility purchased a second vehicle to drive clients to varies actives in the community. Must recently taking clients to the LA car show. According to S1, C1 joined a gym two days ago. LPA reviewed the facility's January activity schedule on today’s visit which revealed at least one planned outing a day for clients. LPA conducted record review of the facilities implemented Program which states although not verbatim, clients are encouraged to independently plan activities. Based on interviews conducted, and documents reviewed there is insufficient information to prove that the allegation may have happened, therefore the allegation "Staff does not ensure clients have planned activities at the facility." is unsubstantiated. Exit interview conducted, report signed and delivered.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023
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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