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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610670
Report Date: 09/25/2024
Date Signed: 09/25/2024 12:04:49 PM

Document Has Been Signed on 09/25/2024 12:04 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TIGERTAIL ADULT HOME 3, INC.FACILITY NUMBER:
197610670
ADMINISTRATOR/
DIRECTOR:		WAULS, ASILIAFACILITY TYPE:
735
ADDRESS:4303 OLIVERA PLACETELEPHONE:
(661) 433-0625
CITY:LANCASTERSTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 0DATE:
09/25/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Asilia Wauls and Chary HallonTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On 9/25/2024, Licensing Program Analyst (LPA) Evelin Rios conducted an announced Pre-Licensing visit to this facility and met with Chary Hallon the Assistant Administrator. Administrator Asilia Wauls met LPA shortly after. This is a change of location application and fire clearance was approved on 08/21/2024. Fire clearance is for four (4) ambulatory clients. The administrator stated the four (4) clients are currently residing at 43139 FENNER AVE, LANCASTER, CA 93536, facility #197609034 and will be moving to this location. The Administrator stated the second living room, dining room, and bedroom furniture will be brought in from the licensed facility prior to residents moving into the home.

LPA confirmed Asilia Wauls and Chary Hallon both participated in Component III with LPA Spaeth on 03/8/2024. Today’s site visit consisted of LPA touring the physical plant inside and outside from 9:30 a.m. until 11:00 a.m. LPA Rios observed the following:

Common Areas: These include two dining areas and two living areas. These areas are spacious and currently one of two living areas has couches that sit the capacity of the facility. One of two dining areas has a large dining table with chairs that sit the capacity of the facility. The rest of the furniture will be moved from the facility #197609034. Cleaning products will be stored in an entry closet that is able to lock. LPA observed two facility telephones in the living areas accessible to clients. Telephone was operational.

Kitchen: The facility contained a seven day supply of non-perishable food. LPA observed a fire extinguisher by the kitchen with a service date 07/30/2024. Appliances such as the gas stove, refrigerator, microwave and dishwasher were observed operational. The medication, first aid, knives, sharps, resident and staff files will be stored in the a kitchen closet that is able to lock and will be inaccessible to clients.
(Continued to LIC809)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/25/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TIGERTAIL ADULT HOME 3, INC.
FACILITY NUMBER: 197610670
VISIT DATE: 09/25/2024
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Bedrooms: There are four bedrooms that were clean and had sufficient lighting. According to the administrator the four client bedrooms will have furniture before the clients arrive. Currently bed, bedding, chair, night stand and dresser is in the clients' bedrooms at the licensed facility.

The smoke detectors are hard wired and interconnected with all smoke detectors through out the facility. Smoke detectors were tested at 9:50 a.m. and were observed operational. LPA observed a carbon monoxide detector by the kitchen and was observed operational. The facility was clean and appears to be in good repair.

Bathrooms: There are three bathrooms of which two are accessible to clients. Each bathroom contained hand soap, paper towels, and a trash bins. There is a linen closet that contained extra clean linens and toiletries. The hot water temperature was tested at approximately 10:00 a.m. and was 115 degrees F.

Laundry Room: The laundry room was locked and will contain the washer and dryer. The laundry room will also contain detergents and cleaning products.

Garage: There is an entrance to garage from the kitchen. It is maintained looked and will be used for facility storage.

Backyard: The backyard will contain a shaded area for residents right out side the sliding door. Work for a permanent patio will be started on 09/27/24 and LPA will receive a picture once it is complete. The side of the house offers shade with an area with grass for activities. Outdoor furniture will be brought from licensed facility before clients move in. The side gate leading from the backyard to the front yard was closed and unlocked.

This report will be forwarded to the Centralized Application Bureau (CAB). Administrator was advised not to move clients to this facility until they are licensed. Pre-Licensing is complete and this facility has no deficiencies. Administrator advised they will be notified by the CAB Analyst about licensure. LPA informed administrator if licensed a follow up visit will be conducted to verify furniture has been moved into the facility.

Copy of report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024
LIC809 (FAS) - (06/04)
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