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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610108
Report Date: 12/07/2022
Date Signed: 12/07/2022 02:43:26 PM

Document Has Been Signed on 12/07/2022 02:43 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:
12/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
07:45 AM
MET WITH:Shary HallonTIME COMPLETED:
09:30 AM
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LPA Spaeth conducted an unannounced visit and was greeted by caregiver who was wearing a mask. LPA observed a resident was leaving the facility to attend high school. Upon entering the facility, LPA observed the COVID signs on the front door. LPA's temperature was taken and recorded. LPA observed the sign in station and LPA was asked to sign in. LPA observed PPE available for guests.

LPA observed the living room contained comfortable seating. The dining room contained a dining table and chairs. LPA observed residents were eating breakfast. The Assistant Administrator and Administrator arrived to the facility at 8:25 am.

LPA and Administrators began tour at 8:30 am until 9:00 am. LPA observed a two-day supply of perishable food items and a seven-day supply of canned goods, cereal, and pasta in the pantry. The kitchen also contained hand soap, paper towels, and a trash can. A storage closet was locked and contained the knives and the residents' medications were locked in a two drawer cabinet. LPA also observed the menu posted in the kitchen and the fire extinguisher was located near the oven.

LPA observed comfortable seating in the backyard and the gate leading to the pool was locked. The side gate leading from the backyard to the front yard was not locked. The garage contained a 90 day supply of PPE.

LPA observed all bathrooms contained hand soap, paper towels, and a trash can. The three resident rooms all contained a bed, linens, lamp and night stand. LPA observed a seating area on the second floor which contained comfortable seating for residents. The staff room was locked and all hygiene items were locked in an upstairs closet. The laundry room is located on the 2nd floor and was locked. The cleaning supplies and laundry detergent were locked in the laundry room.
There are no deficiencies to report at this time. Exit interview was conducted, and a copy of the signed report was given to the Assistant Administrator.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2022
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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