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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610670
Report Date: 11/05/2025
Date Signed: 11/05/2025 12:55:35 PM

Document Has Been Signed on 11/05/2025 12:55 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.RO, 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:
93536
CAPACITY: 4CENSUS: 4DATE:
11/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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On 01/05/2025 at 9:30 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at this facility to conduct an unannounced Required Annual Inspection. LPA was greeted by Staff #1 (S1) who granted access. LPA called the Assistant Administrator Chary Hallon, and explained the reason for the visit. LPA Rios signed in and observed appropriate postings on a wall by the entry. Chary met with LPA at approximately 9:30 a.m., and Administrator Asalia Wauls arrived shortly after that. This is a Level 6 home vendorized by Regional Center.

At 9:44 a.m., LPA along with S1 began a physical plant tour of the facility inside and out and the following was observed:

Bedrooms: There are three (3) client bedrooms upstairs and one (1) downstairs. All bedrooms are private. LPA observed bedrooms to be properly furnished with a bed, night stand, a chair, drawers, sufficient closet space,and adequate lighting. While touring bedrooms LPA met with client #1 (C1), who discussed their bedroom furniture with LPA.

Bathroom: There are two and a half bathrooms. One and a half baths are designated for client use. Bathrooms contained hand soap, paper towels, and toilet paper. Hot water temperature was taken from an upstairs and downstairs bathrooms at approximately 12:26 p.m., and measured within regulation.

Laundry Room: LPA observed the laundry room locked. Laundry room has a washer and dryer that was observed operational. LPA observed detergents, cleaning products and hygiene products in a closet in the laundry room. (Continue to LIC809)

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TIGERTAIL ADULT HOME 3, INC.
FACILITY NUMBER: 197610670
VISIT DATE: 11/05/2025
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(Continued from LIC809) LPA observed dual carbon monoxide detectors and smoke detectors through out the facility that are interconnected and hard wired. The Assistant Administrator tested the detectors at 09:50 a.m. and they were observed operational.

Common Areas: These include the living areas and dining areas. LPA observed dining and living areas clean and clear of clutter with furniture in good repair. Dining and living room furniture sits the capacity of the facility. LPA observed two (2) fire extinguishers fully charged with a serviced date of 07/24/2025.

Kitchen: LPA observed a seven day supply of non-perishable and a two day supply of perishable foods. Facility stores the knives, sharps, first aid kit, client's medications and facility records in a closet that is maintained locked.



Garage: The garage is attached to the facility. In the garage LPA observed a second refrigerator and a deep freezer for the facility.

Backyard: LPA observed an area with appropriate outdoor furniture and shade for clients. Passageways to the exit were clear from obstruction and no bodies of water observed.

Staff/Client Records: At 10:00 a.m., LPA initiated a record review for four (4) out four (4) client records and six (6) staff files to insure compliance with licensing forms.

Medications: LPA with S1 reviewed Centrally Stored Medication Destruction Records and medication for proper documentation. Facility also maintains Medical Administration Records (MAR).



LPA reviewed the facility's Personnel Report (LIC500), Surety Bond, Disaster Plan (LIC610D), Infection Control Plan and last earthquake drill conducted on 09/21/2025.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC809 (FAS) - (06/04)
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