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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 01/24/2022
Date Signed: 01/24/2022 01:53:25 PM

Document Has Been Signed on 01/24/2022 01:53 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
01/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
01:55 PM
NARRATIVE
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On 1-24-22 at 12:24pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit during a complaint investigation for complaint #27-AS-20220120131855. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA interviewed Administrator and reviewed incident report dated 12-26-21. Based on interview and record review it was determined that Resident1 (R1) fell on 12-26-21 and sustain injury. Incident report was submitted to regional office in a timely manner. Upon further review and interview, it was determined that 9-1-1 was not called immediately after the fall incident.

LPA's interview with Administrator also revealed that staff1 (S1) was working alone in the facility and interacted with residents in care on 12-26-21 for a period of time and did not receive a criminal record clearance as per regulations. Staffing list did not include S1 and a reference check through regional office internal records did not reveal a clearance or association of S1 to the facility.

Based on today's visit, citations are issued under Title 22 Division 6, Chapter 8. An immediate civil penalty of $100 is issued due to violation of criminal record clearance. An exit interview was conducted with Adetayo Kokumo and a copy of this report was left with Adetayo. Appeal Rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 01/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/24/2022
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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Document Has Been Signed on 01/24/2022 01:53 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/24/2022 at 12:49 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: TKAS GUEST HOME
FACILITY NUMBER: 392700391

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/25/2022
Section Cited
CCR
87355(b)(D)

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87355 Criminal Record Clearance (b)In addition to the applicant, the provisions of this section shall apply to criminal convictions of the following persons: (D) Any staff person, volunteer, or employee who has contact with the clients. This requirement is not as evidenced by:
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Licensee will read regulation 87355 and submit a signed statement of understanding to LPA by POC due date.

S1 is no longer working at facility and not expected to return per Licensee.
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Based on interview and record review, licensee did not ensure criminal record clearance for S1 who worked at facility on 12-26-21, which poses an immediate health and safety risk to residents in care. An immediate civil penalty of $100 is issued in addition to citation.
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Type A
01/25/2022
Section Cited
CCR87465(g)

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Incidental Medical and Dental Care. (g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...This requirement is not met as evidenced by:
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Licensee will develop and submit a plan to ensure 9-1-1 is called as necessary to meet resident's medical needs

Licensee will read regulation 87465(g) and submit a sign statement of understanding to LPA by POC due date.
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Based on interview and record review, licensee did not ensure timely medical attention. Licensee did not immediately call 9-1-1 after R1 sustained a fall with injury on 12-26-22.
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Licensee to provide training to staff on regulation 86465(g) and submit proof of completed training to LPA by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2022


LIC809 (FAS) - (06/04)
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