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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 01/27/2022
Date Signed: 01/27/2022 05:12:37 PM

Document Has Been Signed on 01/27/2022 05:12 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: 3DATE:
01/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
05:20 PM
NARRATIVE
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On 1-27-22 at 3:15pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit for an incident which occurred on 1-7-22. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. COVID-19 screening questions performed prior to entry. LPA reviewed incident report for Resident1 (R1) dated 1-7-22 and interviewed Administrator. LPA also requested copy of Physician report and pre-admission appraisal for R1 Based on interview, it was determined that R1 exited facility on 1-7-22 at approximately 6:30am and was found by police 30 minutes later, and brought back to facility.

Review of R1’s physician report reveals R1 is able to leave facility unassisted, however, a diagnosis of dementia exists. It was further determined that a pre-admission appraisal was not completed prior to R1’s admission to facility.

As a result of today’s visit, deficiencies are cited under Title 22, Division 6, Chapter 8. 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: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2022
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 01/27/2022 05:12 PM - It Cannot Be Edited


Created By: Michael Bilger On 01/27/2022 at 04:56 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: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2022
Section Cited
CCR
87457(c)

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Pre-Admission Appraisal -General. (c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
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Licensee will complete an updated appraisal form for resident and submit a copy of appraisal to LPA by POC due date.

Licensee will submit a plan to LPA outlining procedures on ensuring pre-admission appraisals are completed for all residents prior to admission.
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This requirement is not met as evidenced by: Based on interview and record review, licensee did not ensure a pre-admission appraisal was completed for R1 prior to R1s admission. 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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Michael Bilger
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2022


LIC809 (FAS) - (06/04)
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