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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 04/30/2025
Date Signed: 04/30/2025 12:47:03 PM

Document Has Been Signed on 04/30/2025 12:47 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:TKAS GUEST HOMEFACILITY NUMBER:
392700391
ADMINISTRATOR/
DIRECTOR:		KOKUMO, ADETAYOFACILITY TYPE:
740
ADDRESS:206 ARC AVETELEPHONE:
(925) 339-0785
CITY:STOCKTONSTATE: CAZIP CODE:
95210
CAPACITY: 6CENSUS: 3DATE:
04/30/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Adetayo KokumoTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
NARRATIVE
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On 4-30-2025 at 10:25am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to continue a case management previously conducted on 4-11-2025. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. During this case management investigation, LPA conducted interviews with Administrator and Staff1 (S1). Additionally, LPA reviewed facility file documentation including physician reports for resident1 (R1), R2, R3, and R4, death report dated 12-28-24, and death certificate pertaining to R1. Additionally, LPA reviewed hospital discharge paperwork. Investigation has determined that R1 passed away on 12-28-2024 with death certificate noting cause of death as acute hypoxemic respiratory failure and aspiration pneumonia. Cause of death was also revealed through hospital discharge paperwork. It was further determined through this case management investigation that staff's actions while on duty did not result in R1 at risk for the above cause of death which was deemed natural causes.
Additional reviews of facility file documentation and staff interviews determined that facility currently provides care for multiple residents with dementia including R2 who is determined to be a wandering and elopement risk. During today's visit, LPA observed R2 attempting to elope from facility. It was further determined that R2 has a history of attempting to elope at various times throughout the day resulting in an on-going risk for elopement. Facility staffing review and interview determined that one staff was on duty for four clients in care including a resident with elopement risk. Additionally, it was determined through observation that facility is not utilizing a staff alert or auditory device to monitor exits on exterior doors.

As a result of today's case management, citations are issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Administrator and a copy of this report was provided. Appeal rights provided.
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Michael Bilger
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/30/2025
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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Document Has Been Signed on 04/30/2025 12:47 PM - It Cannot Be Edited


Created By: Michael Bilger On 04/30/2025 at 12:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TKAS GUEST HOME
FACILITY NUMBER: 392700391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/01/2025
Section Cited
CCR
87411(a)

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Personnel Requirements - General. (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...This requirement is not met as evidenced by:
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Licensee will submit an updated staffing plan sufficient to meet the needs of residents including hours and days worked, including break times and additional coverages. Plan to be submitted to LPA by POC due date
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Based on interviews, observation and record reviews, R2 is established as an elopement risk during the day, with one staff on duty for other residents requiring care and supervision. This poses an immediate health and safety risk to residents in care.
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Licensee to read regulation 87411(a) and submit a signed declaration of understanding to LPA by POC due date.
Type A
05/01/2025
Section Cited
CCR87705(d)

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87705 Care of Persons with Dementia(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement was not met as evidenced by:
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Licensee to submit a plan ensuring appropriate coverage of supervision for residents to prevent elopement. Plan to be submitted to LPA by POC due date.
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Based on observation and interview, Licensee did not ensure alert and monitoring devices on appropriate exterior doors and gates despite knowledge of R2 as an elopement risk. This poses an immediate health and safety risk to residents in care.
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Licensee to submit proof of purchase and plan for installation of alert and monitoring device to LPA by POC due date. Device to be installed within two weeks of citation issuance. Elopement prevention plan to continue before and after device installation.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Liza King
NAME OF LICENSING PROGRAM MANAGER:
Michael Bilger
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/30/2025


LIC809 (FAS) - (06/04)
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