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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700391
Report Date: 02/17/2022
Date Signed: 02/17/2022 04:34:13 PM

Substantiated


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
01/20/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220120131855
FACILITY NAME:TKAS GUEST HOMEFACILITY NUMBER:
392700391
ADMINISTRATOR:KOKUMO, ADETAYOFACILITY TYPE:
740
ADDRESS:206 ARC AVETELEPHONE:
(925) 339-0785
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 3DATE:
02/17/2022
UNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Adetayo KokumoTIME COMPLETED:
02:21 PM
ALLEGATION(S):
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Resident sustained injury while in care
Staff did not maintain proper records of resident's centrally stored prescription medications.
INVESTIGATION FINDINGS:
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On 2-17-22, at 10:29am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the complaint allegations noted above. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA interviewed Administrator, Staff1 (S1) Resident1 (R1), and R2. LPA also reviewed facility care notes and previous incident reports dated 12-13-21, 12-14-21, and 12-26-21. LPA interviewed S2 on 2-15-22. LPA also reviewed physician’s report for R1 and needs and service plan for R1. LPA also reviewed police report dated 12-26-21. Additionally, LPA reviewed medication log sheets and conducted observation of medication storage for R1, R2, and R3.

Allegation #1: Resident sustained injury while in care. LPA interviewed R1, R2, S1, and Administrator. LPA also reviewed incident reports, physician report for R1, and needs and service plan for R1. Based on interviews and record reviews, it was determined that emergency services and police came to the facility on 12-26-21 and attended to R1 who sustained an injury to her left eye and a scratch above left eye. Interview with R1 revealed that R1 had a physical encounter with R2 which led to her injury. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20220120131855
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: 02/17/2022
NARRATIVE
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 Interview with S1 and Administrator revealed that R1 sustained injuries to left eye and a scratch above left eye, however, actual dates of occurrence were not recalled. Police report reviewed states that R1 sustained injuries due to a fall which would have occurred within few days of the 12/26/21 date. Based on interviews with S1, S2, and Administrator, and based on record reviews it was revealed that there were no witnesses to a fall of R1. Interview with R1 also revealed no recalled history of negative interactions with staff members. Interviews with S1, Administrator, R1 and R2 revealed a physical encounter occurred between R1 and R2 which led to an injury of R1 on an unknown date but discovered on 12-26-21. Additionally, it was determined through interview of S1 and Administrator that staff did not immediately intervene during the actual occurrence of the encounter between R1 and R2. It was further discovered through interviews that only 1 staff member was on duty during the encounter, while originally two staff members are present to provide care and supervision. Additionally, it was discovered through record review that R1 has a history of aggressive behaviors towards others. As a result of the interviews conducted and records reviewed, it is determined that R1 sustained injuries while in care during staff presence, and as a result of untimely intervention during the encounter between R1 and R2. Therefore, the preponderance of evidence standard is met and this allegation is SUBSTANTIATED.

Allegation #2: Staff did not maintain proper records of resident’s centrally stored prescription medications. LPA reviewed medication centrally stored medication list and compared information from list to medication observed during medication audit. Based on record review and observation, it is determined that expiration dates for medications, date filled for medications, and start dates for medications did not accurately reflect the dates noted on the medication labels. As a result, the preponderance of evidence standard is met. Therefore, this allegation is SUBSTANTIATED.

Deficiencies are cited today under Title 22, Division 6, Chapter 8. An exit interview was conducted with Adetayo Kokumo and a copy of this report was given to Adetayo. Appeal Rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
01/20/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220120131855

FACILITY NAME:TKAS GUEST HOMEFACILITY NUMBER:
392700391
ADMINISTRATOR:KOKUMO, ADETAYOFACILITY TYPE:
740
ADDRESS:206 ARC AVETELEPHONE:
(925) 339-0785
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY:6CENSUS: 3DATE:
02/17/2022
UNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Adetayo KokumoTIME COMPLETED:
02:21 PM
ALLEGATION(S):
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Staff did not properly assist residents with their medications
INVESTIGATION FINDINGS:
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On 2-17-22, at 10:29am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue investigation for the complaint allegations noted above. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA interviewed Administrator, and Staff1(S1), Resident1(R1), and R2. LPA interviewed S2 on 2-15-22. Additionally, LPA reviewed medication log sheets and conducted observation of medication storage for R1.

LPA reviewed Medication log sheets, medication assessment record (MAR), centrally stored medication, and physician’s orders for R1, R2, and R3 for the months of December 2021, January 2022, and February 2022. LPA also conducted medication observation and audit for R1, R2, and R3. LPA also interviewed R1 and R2. Based on records reviews and interviews, it was determined that medication is being given timely and matching the physician orders. LPA did not observe any expired medication. Based on records reviewed and medication audit, there is not a preponderance of evidence to prove residents are not being properly assisted with their medication. Therefore, this allegation is UNSUBSTANTIATED.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220120131855
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited
CCR
87413(a)(1)
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Personnel Operations: (a)In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:
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Licensee will develop a staffing plan to ensure adequate coverage of staff to meet residents needs. Plan to be submitted by POC due date

Licensee and staff to complete dementia training specific to behavioral interventions. Licensee to send training dates to LPA by POC due date.
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Based on interviews and record reviews, a physical encounter occurred between R1 and R2 on an unknown date while only one staff member was present which led to untimely and safe intervention by staff. Licensee did not ensure sufficient staffing in place. An injury resulted which was discovered on 12-26-21. This poses an immediate health, safety and resident rights risks to residents in care.
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Type B
02/28/2022
Section Cited
CCR
87465(h)(6)(D)
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Incidental Medical and Dental Care. (6)The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (D) The date filled. This requirement is not met as evidenced by:
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Licensee will conduct medication audits for all residents submit correct medication central storage records to LPA by POC due date.
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Based on record review, interview, and medication audit, licensee did not ensure medication storage record for R1 contain an accurate date for date filled, date started, and expiration date as compared to medication labels. This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4