197610088-2-8-2023-31-AS-RRAZ-CQ4PTH-20230320113559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610088
Report Date: 02/08/2023
Date Signed: 02/08/2023 02:14:21 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
02/02/2023 and conducted by Evaluator Evelin Rios

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20230202082635

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:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Chary Hallon		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff are refusing to purchase coffee for resident
Staff made inappropriate comments towards resident

INVESTIGATION FINDINGS:

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On 02/08/2023 at 9:07 a.m. Licensing Program Analysts (LPA) Evelin Rios 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 Administrator Chary Hallon and the purpose of the visit was explained.

From 9:12 a.m. to 10:50 a.m. LPA conducted interviews with two (2) out of the two (2) client present and three (3) staff including the Administrator and toured the facility to insure the health and safety of the residents in care. No issues found at this time. From 10:50 a.m. to 1:40 a.m. LPA obtained and reviewed pertinent documents relevant to the investigation.

Allegation#1 - Staff are refusing to purchase coffee for resident
It was alleged whenever client #1 (C1) runs out of coffee, the staff won’t buy anymore.
(LIC 9099 Continued)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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-20230202082635

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: 02/08/2023

NARRATIVE

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To investigate the allegation LPA reviewed the facility menu which revealed coffee is an item on the menu offered to clients for breakfast on occasion. Interviews with two (2) staff and the administrator confirmed the usual bulk coffee brand had run out and has not been replenished. Instead they offered a different brand which the client took. Interviews with staff revealed although they are out of one brand of coffee they have another brand of coffee. LPA observed a pot of coffee in the client's room. Based on interviews conducted, and LPA's observation this allegation is Unsubstantiated at this time.

Allegation#2: Staff made inappropriate comments towards resident
It is alleged staff made inappropriate comments to C1 and staff ignored C1 by playing on their phone. To investigate the allegation LPA interviewed two (2) clients (C1 and C2) and two (2) out of the (3) staff present. An interview with C1 revealed staff had not said anything, but instead the silence was the offence. Interview with staff revealed when R1 starts to yell or curse at them they do not engage with C1 which may seem like they are ignoring C1. Furthermore, no witnesses could be identified to corroborate the allegation. Based on interviews conducted this allegation is Unsubstantiated at this time.

Exit interview conducted. No citations issued. A copy of this report was provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

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