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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610108
Report Date: 11/17/2024
Date Signed: 11/17/2024 12:32:15 PM

Document Has Been Signed on 11/17/2024 12:32 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/
DIRECTOR:		WAULS, ASILIAFACILITY TYPE:
735
ADDRESS:2139 CORK OAK STTELEPHONE:
(661) 433-0625
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
11/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Ernestine Dorris - StaffTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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An unannounced One (1) year required visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA initially met with staff Ernestine Dorris who called the House manager Rieanna Ellis and explained the purpose of the visit. The Administrator Asilia Wauls also called and designated staff Ernestine Dorris to sign the report. This is a North Los Angeles Regional center (NLARC) vendored facility Level IV-I.

LPA conducted physical plant tour inside and out at 9:45 AM. During the tour, LPA observed that the facility has five (5) bedrooms and three (3) bathrooms. Two (2) bedroom and one (1) bathroom is designated for staff use only. One (1) of the two (2) staff bedroom is being used as an office. The swimming pool at the backyard is appropriately fenced and observed to be locked during visit. This facility is fire cleared for four (4) ambulatory residents.

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage

Bedrooms were toured and observed to be clean and appropriately furnished.
Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 112.3°F to 112.9°F.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2024
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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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: 11/17/2024
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and other toxins were observed to be kept in the locked garage.
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher was observed to be located by the kitchen. Fire extinguisher was observed to be operable and last inspected on 09/27/24. Fire alarms are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector installed in the facility.
Medication were observed to be locked, inaccessible and stored in locked cabinet adjacent to the dining area Knives and sharps are locked and secured in a toolbox inside the medication cabinet. There is a complete first aid kit kept in by the living room area.
Garage is attached to the house with a locked entrance from the kitchen. The garage is also being used as frozen food, PPE, old equipment, decor and other supplies storage. Laundry room is located upstairs and observed to be locked during visit. Laundry detergent and other cleaning agents are kept in the laundry room.
Client records. All four (4) client records were reviewed. Clients record appeared to be complete and current. Staff records were also reviewed. All staff present records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 11/14/24. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2024
LIC809 (FAS) - (06/04)
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