392700391-10-27-2022-27-AS-MBIR-CKM2BQ-20221027171532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 10/27/2022
Date Signed: 10/27/2022 05:17:11 PM

Document Has Been Signed on 10/27/2022 05:17 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 HOME		FACILITY NUMBER:	392700391
ADMINISTRATOR:	KOKUMO, ADETAYO		FACILITY TYPE:	740
ADDRESS:	206 ARC AVE		TELEPHONE:	(925) 339-0785
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95210
CAPACITY: 6		CENSUS: 3	DATE:	10/27/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Adetayo Kokumo		TIME COMPLETED:	03:00 PM

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On 10-27-22 at 2:00pm, regional office conducted an informal meeting with facility to discuss recent citations issued and additional concerns. This meeting was held virtually via Teams Meeting. Present at the meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Licensee Adetayo Kokumo, Ombudsman Kathryn Thomas.

LPA Bilger and LPM King discussed with licensee and assistant administrator the following previous citations and the associated plans of correction going forward:

On 2-17-22 a citation was issued to facility for Personnel Operation 87413(a)(1) due to insufficient staffing. Facility to ensure adequate staffing in place based on evaluation of resident needs.

On 2-17-22 a citation was issued to facility for Incidental Medical and Dental Care 87465(h)(6)(D) due to inaccurate medication storage record. Licensee has conducted training on medication records pertaining to accuracy on dates filled, dates started, and expiration dates as compared to medication labels.

On 1-24-22 a citation was issued to facility for Criminal Record Clearance 87355 due to a staff member present without a criminal record clearance. This staff member is no longer working at facility. Licensee will now ensure all appropriate individuals have criminal record clearance prior to working in the facility. This citation resulted in an immediate civil penalty issuance.

On 1-24-22 a citation was issued to facility for Incidental Medical and Dental Care 87465(g) due to 9-1-1 not immediately called, leading to untimely medical attention for a resident. Licensee conducted training on 9-1-1 protocol per regulatory requirements.

{Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 392700391
	VISIT DATE: 10/27/2022

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On 1-27-22 a citation was issued to facility for Eviction Procedures 87224(a) due to a resident not receiving a 30-day notice of eviction after licensee’s intention to not accept a resident back from a hospital stay. Licensee will now send all 30-day notices to Department prior to issuance to residents. Licensee stated she was not aware of resident’s tendency to wander and exit seek prior to admission.

On 1-27-22 a citation was issued to facility for Pre-Admission Appraisal 87457(c) due a pre-admission appraisal not completed for a resident prior to admission.

On 2-17-22 a citation was issued to facility for Reporting Requirements 87211(b) due to a resident to resident altercation not reported to licensing department, local law enforcement, and ombudsman.

On 2-17-22 a citation was issued to facility for Incidental Medical and Dental Care 87465(g) due to 9-1-1 not notified to address a resident injury.

On 9-26-22 a citation was issued to facility for Prohibited Health Conditions 87615(a)(1) due to a resident retained in facility with stage 3 and stage 4 pressure injuries. Licensee stated she was not aware of resident’s prohibited health condition prior to admission and while conducting assessment. LPA and LPM provide technical support on resident assessments, required needs and service plan updates, and communication with licensing department immediately upon discovery of conditions which may warrant a restricted or prohibited condition for purposes of obtaining necessary waivers and exceptions.

On 9-26-22 a citation was issued to facility for Eviction Procedures 87224(d)(1)(B)(C)(D) due to incomplete eviction letter issued to a resident. Additionally, a citation was issued for 87224(f) due to this letter not sent to licensing per regulatory requirements.

On 9-26-22 a citation was issued to facility for Administrator-Qualifications and Duties 87405(d)(1) due to Administrator not seeking an exemption request for a resident admitted and retained in facility with stage 3 and stage 4 pressure injuries.

On 9-26-22 a citation was issued to facility for Reporting Requirements 87211(a)(1)(D) due to licensee not ensuring written reports sent to licensing after a resident’s multiple admissions to the hospital.

The department is requesting the following to be submitted by the Licensee by 10-28-22:

1. Updated LIC 500 to reflect Administrator’s hours on duty

2. Updated LIC 308 {Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 HOME	FACILITY NUMBER: 392700391
	VISIT DATE: 10/27/2022

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The department is requiring Administrator be on duty at facility for no less than 40 hours per week. Department shall conduct unannounced quarterly visits to ensure compliance with above and all other Title 22 requirements. Quarterly visits shall consist of, but not be limited to: (1) Review of client files, (2) Review of medication administration records for accuracy, (3) Review of incident reports on file (4) Review of staff training records. LPM and LPA notified Administrator that future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and a non-compliance conference to discuss further potential administrative action.

Licensee has agreed to Technical Support Program service (TSP) for additional resources and support.

An exit interview was conducted with Adetayo Kokumo and report was read via phone to Adetayo. A copy of this report was emailed to Adetayo with request for return with signature.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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