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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 02/17/2022
Date Signed: 02/17/2022 04:41:04 PM

Document Has Been Signed on 02/17/2022 04:41 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:
02/17/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
04:41 PM
NARRATIVE
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On 2-17-22 at 2:25pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding complaint # 27-AS-20220120131855. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. During the complaint investigation, LPA reviewed incident report dated 12-26-21 and interviewed Resident1 (R1), R2, Staff1 (S1), and Administrator. Based on interview and record review it was determined that a physical encounter between R1 and R2 occurred on a date not recalled by R1 and R2 nor by S1 and Administrator, and was not reported to licensing department, ombudsman, or local law enforcement. Based on interviews with Administrator and S1, an injury to R1 was later discovered on 12-26-21.

Additionally, it was discovered during complaint visit that on 12-26-21, R1 was discovered to have sustained an injury and 9-1-1 was not called immediately to address the injury.

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: 02/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/17/2022
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 02/17/2022 04:41 PM - It Cannot Be Edited


Created By: Michael Bilger On 02/17/2022 at 03:42 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: 02/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/18/2022
Section Cited
CCR
87211(b)

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Reporting Requirements. (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, and the local law enforcement agency within twenty-four (24) hours as required by Welfare and Institutions Code Section 15630(b)(1).
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Licensee will submit reports of physical encounter to licensing department, ombudsman, and local law enforcement per regulatory requirements. Proof of reports sent to be submitted to LPA by POC due date.

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This requirement is not as evidenced by: Based on interview and record review, R1 and R2 engaged in a physical encounter resulting in injury to R1. Licensee did not ensure this incident was reported to licensing department, local law enforcement, or ombudsman. This poses an immediate health, safety, and resident rights risk to residents in care.
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Licensee will read regulation 87211 and submit a signed declaration of understanding to LPA by POC due date.
Type A
02/18/2022
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 including, but not limited to, an apparent life-threatening medical crisis...This requirement is not met as evidenced by:
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Licensee will read regulation 87465 and submit a signed declaration of understanding to LPA by POC due date.

Licensee will develop a plan to ensure 9-1-1 is called immediately as appropriate to address needs of residents in care. Plan to be submitted to LPA by POC due date.
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Based on interview and record review, an injury to R1 was discovered on 12-26-21, and licensee did not ensure 9-1-1 was called immediately to address injury. This poses and immediate health, safety, and resident rights risks 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: 02/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2022


LIC809 (FAS) - (06/04)
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