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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 04/21/2023
Date Signed: 04/21/2023 12:53:44 PM

Document Has Been Signed on 04/21/2023 12:53 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: 2DATE:
04/21/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Adetayo KokumoTIME COMPLETED:
01:00 PM
NARRATIVE
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On 4-21-23 at 10:02am, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a quarterly health and safety check. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. Health and Safety check is conducted based on a previous informal conference held originally on 10-27-22.

LPA Bilger inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, living area, common TV area, and outside backyard of the facility to ensure compliance with Title 22 regulations. Facility is a 6-bed residential facility for the elderly with a current census of 2. Facility has 6 bedrooms and 3 bathrooms. There is a formal living room and family/TV room for residents. LPA observed 2 bottles of dishwashing liquid in the kitchen unlocked and accessible to residents in care. Resident rights posted. No obstructions to emergency exits noted.

The facility has submitted a COVID mitigation plan. The facility has a designated infection control lead. The facility is able to designate and dedicated a Covid-19 room/bathroom if needed. Common touch surfaces are cleaned after each use. LPA observed outside of facility to contain excess amounts of old mattresses, durable medical equipment, and other furniture stored along side facility backyard. Additionally, facility grounds were overgrown with shrubbery. Bathroom #1 was observed by LPA to contain broken tiles in the shower and excess dirt. LPA further observed a damaged section of a wall near the hallway leading to the bathroom There were 2 staff on duty during LPA's visit today. Water temperature reads between 105*F and 120*F in the bathroom and room temperature reads 68*F. LPA observed the facility to have adequate food supply during today’s visit. .

{Cont. on 809C}
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2023
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: 04/21/2023
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Smoke and carbon detectors were in adequate repair. Facility has an emergency food and water kit. Fire extinguisher is fully charged and dated 10/24/22. LPA requested the following updated documents: LIC 500. LPA reviewed 2 resident files and 2 staff files. LPA also reviewed medication log sheets and incident reports since February 2023. All regulatory contents in staff and resident files were present.

Per California Code of Regulations, Title 22, deficiencies were observed during this visit. Exit interview was held and a report was given to Administrator Adetayo Kokumo. Appeal rights provided.

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/21/2023 12:53 PM - It Cannot Be Edited


Created By: Michael Bilger On 04/21/2023 at 12:05 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: 04/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2023
Section Cited
CCR
87309(a)

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Storage Space. (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Licensee secured dishwashing liquid during LPA's visit, and will install a lock under the kitchen sink for permanent storage. Licensee to submit a photo proof of lock installed to LPA by POC due date.
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Based on observation, Licensee did not comply with above regulation. Two containers of dishwashing liquid were observed by LPA to be accessible to residents in care. This poses an immediate health and safety risk to residents in care.
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Licensee will read regulation 87309(a) and submit a signed declaration of understanding to LPA by POC due date.
Type B
05/01/2023
Section Cited
CCR87303(a)

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Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not as evidenced by:
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Licensee will remove excessive materials, repair or replace broken tiles in bathroom, repair damaged wall., and contract with lawn service to maintain shrubbery. LPA to send photo proof of repairs and lawn service to LPA by POC due date.
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Based on observation, LPA observed excessive amounts of aging materials stacked up and stored outside, overgrown shrubbery in backyard, dirty and broken tiles in bathroom shower, and wall damage. This poses a potential health and safety risk to residents in care.
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Licensee to conduct audit of entire facility and develop a plan for maintaining a clean, safe, and sanitary environment. Plan to be submitted to LPA by POC due date.
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: 04/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/21/2023


LIC809 (FAS) - (06/04)
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