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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700391
Report Date: 03/02/2022
Date Signed: 03/02/2022 04:36:51 PM

Unsubstantiated


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
02/24/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220224105810
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:
03/02/2022
UNANNOUNCEDTIME BEGAN:
10:41 AM
MET WITH:Adetayo KokumoTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff force resident to take medication
Staff give medications to resident that have not been authorized by resident's physician
INVESTIGATION FINDINGS:
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On 3-2-22, 10:41pm Licensing Program Analyst (LPA) Michael Bilger opened and investigated a complaint for the allegations noted above. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA requested the following documents: Medication log sheets for Resident1 (R1), for February and March of 2022, Central storage medication list for R1 for February and March of 2022, and staff medication training records. LPA also interviewed R1, Administrator, and Staff1 (S1), and R1's physician. LPA also conducted medication audit of stored medication and reviewed current physician orders for R1. Additionally, LPA conducted facility observation.

Based on interviews, record reviews and observations it was determined that resident has been receiving medications as ordered and on time for February and March of 2022. Additionally, LPA observed medications stored at facility to match physician orders and medication log sheets. An interview with R1's physician on 3-2-22 verified medication listed are current as ordered. An observation of facility and medication audit by LPA on 3-2-22 did not reveal additional medication stored beyond resident's currently prescribed medication. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
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 2
Control Number 27-AS-20220224105810
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: 03/02/2022
NARRATIVE
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A review of medication training records revealed that training is current. Based on additional interviews, it was revealed that there was no observation of R1 being forced to take any medications against resident's will. Record review revealed that medications are documented appropriately to indicate when medication is taken or refused.

Based on observations, interviews, and record review it is determined that the preponderance of evidence standard is not met, therefore, these allegations are UNSUBSTANTIATED.

An exit interview was conducted with Administrator Adetayo Kokumo and a copy of this report was given to Adetayo.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2