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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700391
Report Date: 09/26/2022
Date Signed: 09/26/2022 12:36:01 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
07/19/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220719142225
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: 4DATE:
09/26/2022
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Adetayo KokumoTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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9
Resident sustained pressure injury while in care
Resident is being evicted illegally
Resident's paperwork was incomplete
INVESTIGATION FINDINGS:
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On 9/26/22 at 10:17am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegations noted above. LPA met with administrator Adetayo Kokumo and explained the purpose of the visit. During this investigation, LPA interviewed Administrator and Resident1 (R1). LPA also reviewed hospital and home health records pertaining to R1 as well as facility file documentation including R1’s admission agreement, needs and service plan, physician’s report, care notes, eviction notice, and a hospital agreement with facility.
Allegation #1: Resident sustained pressure injuries while in care. LPA reviewed home health and hospital notes pertaining to wound care for R1. LPA also interviewed administrator and R1. LPA also reviewed care notes, needs and service plan, and physician’s report for R1. Based on record review and interviews, it was determined that R1 was admitted to facility from hospital with pressure injury on buttocks described as stage 4 in addition to other pressure injury on right ankle described as stage 3. It was further determined that home health services began a certification period of 4-11-22 and identified the buttocks pressure injury as Stage 3 in addition to other pressure injuries on right ankle which were written as unstageable. {Cont. on 9099C}
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
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 6
Control Number 27-AS-20220719142225
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: 09/26/2022
NARRATIVE
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Interviews further revealed R1 was admitted with pressure injuries on 11/19/21. Additional record reviews indicate pressure injuries were not identified on physician’s report. Care notes indicate R1 was sent multiple times to the hospital during his residency at facility. Based on record reviews and interviews, it is determined that R1 was admitted to facility with a stage 4 pressure injury and additional pressure injuries, which were sustained as a prohibited condition during his residency. Furthermore, department does not have evidence of an exception request from facility for purposes of R1’s residency with stage 3 and 4 pressure injuries. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation #2: Resident is being illegally evicted. LPA reviewed eviction notice for R1 dated 5-26-22. Based on review of notice and interview, it is determined that facility issued this notice to R1 but did not obtain a signature from R1 or R1’s responsible person. Additionally, eviction notice was not sent to Department as required per regulations. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Allegation #3; Resident’s paperwork was incomplete. LPA reviewed eviction notice for R1 dated 5-26-22. Based on review of notice and interview, it is determined that facility issued this notice to R1, and stated reasons for eviction, however, did not include specific facts and circumstances concerning those reasons as per regulatory requirements. Additionally, facility did not include appropriate regulatory language including an unlawful detainer statement and additional resources for alternative housing. As a result, the preponderance of evidence standard is met, and this allegation is SUBSTANTIATED.

Citations are issued today based on Title 22, Division 6, Chapter 8 and noted on LIC 9099D. An exit interview was conducted with Adetayo Kokomo and a copy of this report was left with Kokomo. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
07/19/2022 and conducted by Evaluator Michael Bilger
COMPLAINT CONTROL NUMBER: 27-AS-20220719142225

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: 4DATE:
09/26/2022
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Adetayo KokumoTIME COMPLETED:
12:05 PM
ALLEGATION(S):
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3
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9
Facility did not accept resident back after hospitalization.
INVESTIGATION FINDINGS:
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On 9/26/22 at 10:17am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to deliver complaint findings for the allegation noted above. LPA met with administrator Adetayo Kokumo and explained the purpose of the visit. During this investigation, LPA interviewed Administrator and Resident1 (R1). LPA also reviewed facility file documentation including R1’s admission agreement, needs and service plan, care notes, eviction notice, and a hospital agreement with facility.
Based on interviews and record reviews, it was determined that on 6-29-22, R1 called 9-1-1 requesting to be sent to hospital and declined to remain in facility at that time. Care notes reviewed revealed that R1 was sent to hospital multiple times between admission date of 11/19/21 and discharge date of 6/29/22 with returns to facility noted. Interviews conducted and records reviewed also revealed that R1 did not return to facility after 6-29-22, and responsible person retrieved R1’s personal belongings on 7-18-22. Interviews further indicate that R1 did not attempt to return to facility after discharge. Based on records reviewed and interviews conducted, it is determined that R1 left facility through R1’s initiated call to 9-1-1 on 6-29-22 due to not wishing to remain in facility, and did not return. {Cont. on 9099C}
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
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 6
Control Number 27-AS-20220719142225
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: 09/26/2022
NARRATIVE
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As a result, the preponderance of evidence standard is not met, and this allegation is UNSUBSTANTIATED.

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

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 27-AS-20220719142225
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: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/27/2022
Section Cited
CCR
87615(a)(1)
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Prohibited Health Conditions.(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:
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Licensee will read regulation 87615 and submit a signed declaration of understanding to LPA by POC due date.
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Based on record reviews and interviews, R1 was admitted to facility on 11-19-22 with stage 4 and stage 3 pressure injuries and sustained these injuries throughout R1’s residency. This posed an immediate health and safety risk to resident in care.
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Licensee will ensure completion of staff training on Prohibited Health Conditions and submit a training date to LPA by POC due date. Training to be completed no later than 2 weeks after the issuance of this citation and proof of training to be sent to LPA prior to citation clearance.
Type B
10/06/2022
Section Cited
CCR
87224(d)(1)(B)(C)(D)
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Eviction Procedures. (d) The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination…concerning those reasons. (1) The notice to quit shall include the following information: (B) Resources available to assist…(C) A statement informing residents of their right to file a complaint with the licensing agency…and the State Long Term Care Ombudsman office. (D) The following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date...facility...must file an unlawful detainer action”…This requirement is not met as evidenced by:
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Licensee will read regulation 87224(d)(1)(B)(C)(D) and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review and interview, licensee did not ensure an eviction noticed for R1 dated 5-26-22 contained appropriate resources available, rights to appeal, and unlawful detainer statement. This posed a potential health, safety, and resident rights 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: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 27-AS-20220719142225
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: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited
CCR
87224(f)
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Eviction Procedures. (f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement was not met as evidenced by:
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Licensee will read regulation 87224(f) and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review and interview, licensee did not ensure an eviction notice for R1 dated 5-26-22 was sent to licensing agency per regulatory requirements or signed by resident or responsible person. This posed a potential health, safety, and resident rights 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: 09/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6