197610088-1-4-2023-31-AS-RRAZ-CPRMKJ-20230309084049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 01/04/2023
Date Signed: 01/04/2023 02:20:36 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
12/27/2022 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20221227120123

FACILITY NAME:	TIGERTAIL ADULT HOME 4, INC.		FACILITY NUMBER:	197610088
ADMINISTRATOR:	HALLON, CHARY		FACILITY TYPE:	735
ADDRESS:	43418 62ND STREET WEST		TELEPHONE:	(661) 433-0625
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	4	CENSUS: 3	DATE:	01/04/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Chary Hallon		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff speaks inappropriately to client
Staff is not meeting the clients dietary needs
Staff did not safeguard clients cash resources

INVESTIGATION FINDINGS:

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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, LPAs were greeted by staff #1 (S1) and granted 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.

Staff speaks inappropriately to client.
To investigate this allegation, LPAs conducted interviews at 11:45 a.m. with the Licensee, Administrator and Staff #1(S1) on today’s visit. One staff interview with Staff #3 (S3) was conducted on a separate complaint visit by LPA Ruiz on 9/22/2022. Interviews with Licensee, Administrator and staff revealed that no staff speak inappropriately to any client, specifically C1. Interview with S3 revealed C1 speaks to S3 in a derogatory manner without provocation. Based on interviews conducted, there is insufficient information to prove that the allegation may have happened, therefore the allegation "staff speaks inappropriately to client" is unsubstantiated.

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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Control Number 31-AS-20221227120123

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: 01/04/2023

NARRATIVE

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Staff is not meeting the client’s dietary needs
To investigate this allegation, LPA conducted record review and interviews. At 11:45 a.m., LPA reviewed C1’s physician report dated 9/14/2022, and LPA did not observe any special diet requests or specific diet needs on the physician report. Interviews with both S1 and S2 revealed that due to C1’s diabetes, C1 prefers low sugar products and items from specific grocery stores. Both staff state that when they do grocery shopping, they always try to accommodate C1’s requests for specific food items and have a set budget for C1’s zero sugar products such as coffee creamer. S1 provided to LPA pictures of varies groceries requested by C1. Based on record review and interviews, the allegation mentioned above is deemed Unsubstantiated.

Staff did not safeguard clients cash resources.
To investigate this allegation, LPA conducted interviews and record review. It was alleged that C1 had their wallet with money missing or stolen. LPA conducted interviews with S1 and S2 to which both stated that months ago, C1 alleged that their wallet was missing/stolen. Both staff stated that they believe another client could have stolen the wallet from C1’s room, but there was no way of proving it. Additionally, LPA reviewed an incident report dated 8/16/2022, which reveals that the facility conducted their own investigation and interviews with staff and clients, but the wallet was never found nor was anyone found guilty of taking it. Based on record review and interviews, there is not sufficient evidence to prove that staff did not safeguard clients cash resources, therefore the allegation mentioned above is Unsubstantiated.

Exit interview conducted, report signed and delivered.

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

LIC9099 (FAS) - (06/04)

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