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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 07/27/2023
Date Signed: 07/27/2023 02:04:44 PM

Document Has Been Signed on 07/27/2023 02:04 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:
07/27/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
01:59 PM
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On 7-27-23 at 1pm, a meeting was held with Licensee to review previous engagements by Department’s Technical Support Program (TSP). This meeting was held virtually via Teams Meeting. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, and Licensee Adetayo Kokumo. Topics discussed in this meeting included (1) Care and Supervision, (2) Record Keeping, and (3) Incident Reporting.

TSP conducted engagement meetings with Licensee on the dates of 1/31/23, 3/29/23, and 3/30/23. TSP addressed care and supervision to included licensee’s assurance of following Title 22 regulations regarding prohibited health conditions and the challenges regarding the acceptance of residents with such conditions resulting in non-compliance. TSP provided training resources and other recommendations. Licensee stated during the meeting that she will continue to provide more detailed assessments for new and on-going residents in care to ensure Licensee and staff are able to meet care and supervision needs.

TSP addressed record keeping as an area of focus for Licensee due to history of non-compliance. TSP addressed the challenges with licensee conducting and documenting resident assessments and re-assessments. TSP provided training resources and other recommendations to aid in Licensee’s future compliance with this regulated section. {Cont. on 809C}

SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/27/2023
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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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: 07/27/2023
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Licensee stated during the meeting that she understands the importance of updated the needs and service plans as well as re-appraisals. Additionally, Licensee is aware of when to update these forms for purposes of identifying and caring for new conditions.

TSP addressed incident reporting as an additional area of focus for Licensee. TSP addressed Licensee’s challenges with ensuring incident reports were being submitted appropriately and in a timely manner. TSP provided training resources and additional recommendations in this area to help Licensee maintain compliance. Licensee stated during the meeting that she is continuing to send licensing reports involving warranted events such as 9-1-1 calls. Licensee stated she understands the need to document such events.

Licensee was made aware that quarterly visits will continue at this time to ensure the compliance with above and overall regulatory compliance. LPM and LPA notified Licensee 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.

No citations issued as a result of today’s visit. An exit interview was conducted with Licensee Adetayo Kokumo and a copy of this report was emailed to Licensee with a request to return with signature.

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

DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2023
LIC809 (FAS) - (06/04)
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