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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610543
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:23:41 PM

Document Has Been Signed on 03/08/2024 12:23 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, INC.FACILITY NUMBER:
197610543
ADMINISTRATOR:HALLON, CHARYFACILITY TYPE:
735
ADDRESS:40608 55TH STREET WESTTELEPHONE:
(661) 675-4466
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 0DATE:
03/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Asilia Wauls and Chary HaltonTIME COMPLETED:
12:00 PM
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On 3/08/2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced pre-Licensing visit to this facility and met with the Licensee and Administrator. This is a new application and a fire clearance dated 12/20/2023 was received for four (4) ambulatory residents. The Licensee stated the four (4) clients residents at 43131 Hampton, Lancaster, Ca 93536, Facility #197609616 will be moving to this location. The Administrator stated the living room, dining room, and family room furniture from 43131 Hampton will be moved to the facility prior to residents moving into their rooms. The four bedrooms at the new location are fully furnished at this time.

The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. Component III was conducted with the applicant from 10:00 am until 11:00 am

Today’s site visit consisted of LPA touring the physical plant inside and outside from 11:00 am until 11:20 am. LPA Spaeth observed the following:

Living Room – the living room is spacious and the furniture will be moved from the 43131 Hampton location to the new facility location. The Licensee stated the room will contain comfortable seating.

Kitchen/Dining Room - The facility contained a seven-day supply of non-perishable food and a two-day supply of perishable foods. A fire extinguisher is also located in the kitchen. Appliances in the kitchen appeared to be functional. The dining room area is spacious and the dining room furniture from the 43131 Hampton location will be moved to the new location prior to the residents moving into the new facility.

Family Room– LPA observed the family room was spacious.
Continued - 809C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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, INC.
FACILITY NUMBER: 197610543
VISIT DATE: 03/08/2024
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Backyard - The backyard contained a shaded area for residents to enjoy outside activities. The side gate leading from the backyard to the front yard was not locked.

Bedrooms - There are four bedrooms which contained bed, linens, night stand, lamp, chest of drawers, a chair and a closet.

Bathrooms- There are three bathrooms which contained hand soap, paper towels, and trash can.

Hallway - There are two hallway closets. The medication, first aid kid, additional PPE supplies, and the knives will be locked in the hallway closet with a special lock. The linen closet contained clean linens.

Laundry Room – the laundry room was locked and contained the washer and dryer.

Garage – the garage was locked and did not contain any harmful items.

The smoke and carbon monoxide detectors were tested at 11:40 am and were operable. The water temperature was tested at 11:45 am and was 105.9 degress F. The facility was clean and appears to be in good repair.

This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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