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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 12:43:38 PM

Document Has Been Signed on 09/26/2022 12:43 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:
12:25 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
01:05 PM
NARRATIVE
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On 9-26-22 at ,12:25pm Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit. LPA met with Administrator Adetayo Kokomo and explained the purpose of the visit. During the course of an investigation related to complaint #27-AS-20220719142225, it was determined that Resident1 (R1) was admitted to facility with Stage 4 and Stage 3 pressure injuries. It was further determined that Administrator did not ensure proper communication with the Department to seek an exception for proper care and supervision during R1’s residency as required per regulations.

As a result of today’s visit, citation is issued under Title 22, Division 6, Chapter 8. An exit interview was conducted with Adetayo Kokomo 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 12:43 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/26/2022 at 11:26 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 A
09/27/2022
Section Cited
CCR
87405(d)(1)

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Administrator-Qualifications and Duties. (d) The administrator shall have the qualifications specified…(1) Knowledge of the requirements for providing care and supervision appropriate to the residents. This requirement is not met as evidenced by:
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Administrator will read regulation 87405 and submit a signed declaration of understanding and commitment to adhere to the regulatory requirements.
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Based on records review and interview, Administrator did not ensure an exception request for R1 who was admitted to facility on 11-19-21 with Stage 4 and Stage 3 pressure injuries. This poses an immediate 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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