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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 09/26/2022
Date Signed: 09/26/2022 12:42:19 PM

Document Has Been Signed on 09/26/2022 12:42 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:
09/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:05 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
12:25 PM
NARRATIVE
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On 9-26-22 at 12:05pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management related to previous incidents regarding resident1 (R1). LPA met with Administrator Adetayo Kokomo and explained the purpose of the visit. LPA reviewed care notes for R1 and interviewed Administrator. Based on records reviewed and interview, it was determined that R1 was sent to the hospital multiple times between 11-19-21 and 6-29-22. It was further determined that incident reports were not received by licensing per regulatory requirements regarding multiple episodes of R1’s hospitalization between the above time periods.

As a result of today’s case management, citation is issued 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: 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/26/2022 12:42 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/26/2022 at 11:17 AM
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: 09/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements. (a) Each licensee shall furnish to the licensing agency:…(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of…(D) Any incident which threatens the welfare, safety, or health of any resident...This requirement was not met as evidenced by:
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Licensee will read regulation 87211(a)(1)(D) and submit a signed declaration of understanding to LPA by POC due date.
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Based on record review and interview, R1 was sent to the hospital multiple times between 11/19/21 and 6/29/22, and licensee did not ensure a written report sent to licensing within this time frame for multiple episodes. 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: 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


LIC809 (FAS) - (06/04)
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