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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 09/27/2023
Date Signed: 09/27/2023 03:57:20 PM

Document Has Been Signed on 09/27/2023 03:57 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:
09/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
04:00 PM
NARRATIVE
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On 9-27-23 at 3:00pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management regarding absence without leave (AWOL) incidents which occurred on 6-24-23 and 8-6-23. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA reviewed incident reports and physician's report for resident1 (R1) and R2. LPA also interviewed Administrator. Based on record reviews and interviews, the following incidents occurred:

Incident #1: On 6-24-23, according to incident report dated 6-25-23, resident1 (R1) exited facility at approximately 12 noon on 6-24-23. R1 was admitted to facility at approximately 7:00pm on 6-23-23. Based on interview, R1 was observed by staff to be laying in bed prior to 12 noon. Staff member on duty went into the kitchen to prepare meals and later checked on R1 to determined R1's whereabouts. Staff member then noticed R1 was not in his room. Staff member searched throughout the facility inside and out, and drove throughout the community to search for R1. R1 was unable to be located resulting in an absence of supervision. Staff member then called police to file a report. At this time, R1 has not been located. Physician's report reviewed states R1 is unable to leave facility unassisted.

Incident #2: On 8-6-23, according to incident report, resident2 (R2) became combative with another client and a staff member. R2 shoved staff1 (S1) and continued to engage in yelling. R2 then proceeded through facility door and walk down the street. S1 on duty proceeded to follow R2 down the street until R2 began running at which time S1 lost sight of R2 resulting in an absence of supervision. S1 then notified police to file a report. R2 was located and is now currently residing in the facility. Physician's report reviewed states R2 is unable to leave facility unassisted.

As a result of today's case management, citations are issued under Health and Safety Code, chapter 3.2. An immediate civil penalty in the amount of $500 is issued due to occurrence of absence of supervision. An exit interview was conducted with Adetayo Kokumo and a copy of this report was provided to Adetayo. Appeal rights provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2023
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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Document Has Been Signed on 09/27/2023 03:57 PM - It Cannot Be Edited


Created By: Michael Bilger On 09/27/2023 at 02:18 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: 09/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2023
Section Cited
HSC
1569.312(d)

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Basic Service Requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: (d) Being aware of the resident's general whereabouts...This requirement was not met as evidenced by:
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Licensee will submit a plan to ensure residents general whereabouts are known by staff. Plan to include but not be limited to: Location within facility and documentation to indicate when checks are completed. Plan to be submitted to LPA by POC due date.
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Based on record reviews and interviews, R1 and R2 exited facility on separate dates and facility was unaware of whereabouts for residents, resulting in an absence of supervision. This posed 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: 09/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2023


LIC809 (FAS) - (06/04)
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