<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610108
Report Date: 11/29/2023
Date Signed: 11/29/2023 03:05:38 PM

Document Has Been Signed on 11/29/2023 03:05 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
WOODLAND HILLS S.ASC, 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:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Chary HallonTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the Administrator. LPA stated the purpose of the visit was to conduct an annual inspection. The Administrator confirmed there are four residents. The facility is licensed for four residents. The Licensee arrived at 10:30 am.

LPA Spaeth and the Administrator toured the location at 10:00 am until 10:30 am. LPA observed the facility was neat and clean.

Common Areas – LPA observed the living room contained comfortable seating. The dining room is furnished with table and chairs. The family room contained comfortable seating and a television.

Hallway Closet- LPA observed the closet was locked and contained resident medications, first aid kit, resident hygiene items, cleaning solutions, and knives.

Kitchen – LPA observed a two-day supply of perishable foods and a seven-day supply of nonperishable foods. LPA observed there were no safety issues in the kitchen. LPA tested the water temperature at 10:15 am which was 106.1 degrees F.

Resident Bedrooms - There are three resident bedrooms which are furnished with a bed, linens, night stand, chest of drawers and a closet.

Laundry Room - The laundry room was locked and contained washer/dryer and laundry soap.

Bathroom – There are two bathrooms in the facility which contained hand soap, paper towels and a trash can.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TIGERTAIL ADULT HOME II, INC.
FACILITY NUMBER: 197610108
VISIT DATE: 11/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff Room - LPA observed the staff room was locked

Staff Office – LPA observed staff office located on the second floor of the facility.

Backyard - LPA observed the backyard has a shaded area with comfortable seating. The side gate leading from the backyard to the front yard was not locked. LPA observed a locked fence surrounds the swimming pool.



Garage - LPA observed the garage was locked. An additional refrigerator is located in the garage and contained additional frozen food items and water. The emergency water was stored in the garage.

Smoke/Carbon Monoxide Detectors – The detectors were tested at 10:25 am and were operable.



LPA reviewed residents' and staffs' records at 11:15 am until 12:20 pm. LPA reviewed resident medications at 12:20 pm until 12:55 pm. LPA observed the P&I with Administrator at 1:15 until 1:30 pm.

There are no deficiencies to report. The exit interview was conducted, and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2