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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610543
Report Date: 02/06/2025
Date Signed: 02/06/2025 03:29:53 PM

Document Has Been Signed on 02/06/2025 03:29 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/
DIRECTOR:		HALLON, CHARYFACILITY TYPE:
735
ADDRESS:40608 55TH STREET WESTTELEPHONE:
(661) 675-4466
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Asilia WaulsTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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On 02/06/2025, Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit to this facility and met with the Licensee. The facility is licensed for four ambulatory residents. LPA was met by the Licensee.

LPA Spaeth reviewed the residents'' files at 9:55 am until 10:30 am. LPA reviewed staff files at 10:40 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 contained a dining room table and chair.

Kitchen/Family 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 family room contained comfortable seating and a television

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.


Continued - 809C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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: 02/06/2025
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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 supplik. 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 contained the knives and additional food including the emergency food supply.

The smoke and carbon monoxide detectors were tested at 11:26 am and were operable. The water temperature was tested at 11:20 am and was 111 degrees F. The facility was clean and appears to be in good repair.

LPA Spaeth reviewed the client medications at 11:20 am until 11:30 am.

There are no deficiencies to report at this time.

Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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