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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610108
Report Date: 11/05/2021
Date Signed: 11/05/2021 04:55:24 PM

Document Has Been Signed on 11/05/2021 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 II, INC.FACILITY NUMBER:
197610108
ADMINISTRATOR:WAULS, ASILIAFACILITY TYPE:
735
ADDRESS:2139 CORK OAK STTELEPHONE:
(661) 433-0625
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Shary Hallon TIME COMPLETED:
03:30 PM
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LPA Spaeth conducted an unannounced visit to the facility and was greeted by caregiver, Ernestine Dorris. Caregiver asked COVID questions and also took LPA's temperature. LPA observed the sign in sheet which contained hand sanitizer, thermometer, and additional masks.

Shary Hallon and Dolly Wauls arrived at 2:45 pm and began the tour with LPA Spaeth. LPA observed a locked hall closet which contained the residents' medications, knives, and household cleaning supplies. The downstairs bathroom contained wash your hands sign, hand soap, paper towels and a trash can. LPA observed the living room contained comfortable furniture. All parties entered the kitchen/family room and LPA observed three residents watching television.

LPA Spaeth viewed the kitchen and observed there were no cleaning supplies or chemicals underneath the sink. LPA observed fruits on the kitchen table available for residents. LPA also observed fresh fruits, vegetables, eggs, milk, and frozen meats in the refrigerator. There was an adequate supply of canned goods and pasta in the pantry room. LPA observed the garage was locked. LPA Spaeth observed the backyard and saw the gate for the swimming pool was locked. LPA observed the side gate was unlocked.

LPA was then escorted to the second floor and observed two resident rooms which contained a bed, linens, lamp, and night stand. All rooms were neat and clean. LPA observed the residents' upstairs bathroom contained wash your hands sign, hand soap, paper towels, and a trash can. Caregiver unlocked the laundry room and LPA observed the laundry room contained the laundry detergent. Caregiver then unlocked a closet which contained additional hygiene items and PPE supplies which consisted of gowns, surgical gowns, and N95 masks.

There are no deficiencies to report at this time. Exit interview conducted, appeal rights discussed, and a copy of the signed report was given to staff.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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