392700391-2-17-2021-27-AS-KHOS-BYHKME-20210223070125

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700391
Report Date: 02/16/2021
Date Signed: 02/17/2021 02:20:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/20/2020 and conducted by Evaluator Albert Johnson

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20200820131151

FACILITY NAME:	TKAS GUEST HOME		FACILITY NUMBER:	392700391
ADMINISTRATOR:	KOKUMO, ADETAYO		FACILITY TYPE:	740
ADDRESS:	206 ARC AVE		TELEPHONE:	(925) 339-0785
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY:	6	CENSUS: 6	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Adetayo Kokumo		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff do not answer the phone.
Family members are unable to visit with the resident.
There is no supervisor present during the day.
The resident threatened with eviction.
SSI resident was given notice of rent increase.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Albert Johnson conducted a call to the facility regarding the complaint investigation with the above allegations. LPA talked with Administrator and explained the purpose of today's call to deliver investigation findings.

Allegations: Staff do not answer the phone. Based on records reviewed and interviews by LPA Johnson with Resident's Families and Licensee. The facility has an operating landline (209) 227-5958 and the Licensee has a cell phone that she has with her 24/7. The facility land line is used by the residents and may not be answered when being used by the residents. LPA has made calls to both lines and confirmed that both lines are operational. The land line has call waiting and may not been switched over when incoming calls are placed.

Unsubstantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20200820131151

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TKAS GUEST HOME	FACILITY NUMBER: 392700391
	VISIT DATE: 02/16/2021

NARRATIVE

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Allegations: Family members are unable to visit with the resident. Based on the information provided by the Center for Disease Control (CDC) the facilities were given directives to not allow visitor unless they were essential workers. The facility was in the mist of a surge with a death reported. To minimize the continued spread of the virus the visits from family members were discouraged.

Allegation: There is no supervisor present during the day. The facility has on record a "Designated Responsible Staff" when the Administrator is not available or out of the facility. The Administrator does not have to be at the facility, however, when the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility. The facility has arrangements for this requirement.

Allegation: The resident threatened with eviction. Based on interviews with Licensee/Administrator the threat of eviction was denied, the Licensee mentioned that the family refused to pay on an agreed amount and this was a verbal agreement between both parties. Licensee confirmed that after researching SSI requirements and regulations, she rescinded the request to increase the facility rate.

Allegation: SSI resident was given notice of rent increase. Based on interviews with the Licensee and review of documents , R1 moved into the facility prior to becoming Medi-Cal approved and information was shared verbally between parties about the amount of rent to be paided. The facility has agreed to provide R1 with services at the originally agreed rate and has not requested an increase or given notice to move.

The Department has investigated the about allegations and determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted with Administrator. Copy of the report sent to Licensee via e-mail with a "read receipt" to verify the LIC 9099 was received. Licensee is to print out each report, and fax a signed copy to LPA at 916-263-4744.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

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