197610088-1-4-2023-31-AS-NGID-CNCTQL-20230123135608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 01/04/2023
Date Signed: 01/04/2023 02:15:04 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
06/21/2022 and conducted by Evaluator Melissa Ruiz

COMPLAINT CONTROL NUMBER: 31-AS-20220621141446

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:	02:20 PM

ALLEGATION(S):

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Staff do not ensure resident's special diet is followed.
Staff failed to safeguard residents’ belongings.
Resident not being provided their PNI.

INVESTIGATION FINDINGS:

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On 1/4/2022, Licensing Program Analysts (LPAs) Melissa Ruiz and Evelin Rios arrived at the facility to conduct an unannounced subsequent complaint investigation. Upon arrival, LPAs were greeted by two staff (S1 & S2) and later met with the Administrator and Licensee. LPA conducted an entrance interview, and the purpose of the visit was explained.

Staff do not ensure resident's special diet is followed.

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 request on the physician report. Interviews with both S1 and S2 revealed that there is no special diet they must abide by, but that 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. Based on record review and interviews, the allegation mentioned above is deemed Unsubstantiated.
Staff failed to safeguard residents’ belongings.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
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-20220621141446

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: 01/04/2023

NARRATIVE

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To investigate this allegation, LPA conducted record review and at 11:35 a.m., LPA reviewed the Client/Resident Personal Property and Valuables (LIC621). There were various items listed, including C1’s phone and other personal items. It was alleged that C1’s phone was missing or stolen. LPA conducted interviews with S1 and S2 to which both stated that months ago, C1 alleged that their phone was stolen. Both staff stated that they spent days searching for the missing phone, but it was never found. Both staff believe that C1 has misplaced the phone, and C1 was taken to get a new phone the next day. Based on record review and interviews, there is not sufficient evidence, therefore the allegation mentioned above is Unsubstantiated.

Resident not being provided their PNI.

To investigate this allegation, LPA conducted record review at 11:22 a.m. and LPA reviewed C1’s admission agreement from NLARC which states that the resident or resident’s payee will handle the resident’s cash resources. An interview with the Administrator and Licensee revealed that when C1 was admitted to the facility, C1’s family member was their payee, and they were receiving C1’s PNI monies, as stated in the admission agreement. Per the Licensee, it was brought to their attention C1’s family member was not issuing the PNI funds, and as of today, the licensee is now the payee, to which the Licensee distributes C1’s PNI money monthly. Based on record review and interviews, the allegation is Unsubstantiated.
No deficiencies issued during today’s visit. Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
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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