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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700391
Report Date: 02/21/2024
Date Signed: 02/21/2024 03:54:39 PM

Document Has Been Signed on 02/21/2024 03:54 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
02/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:23 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
04:15 PM
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On 2-21-24 at 2:23pm, Licensing Program Analyst (LPA) Michael Bilger arrived at facility unannounced to conduct a case management visit regarding a previous resident to resident confrontation. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA reviewed incident report dated 12-25-23 and conducted brief interview with Administrator. Based on review of incident report, on 12-25-23, resident1 (R1) approached R2 stating negative verbalization towards R2. Administrator redirected R1 at that time. At a later time during the night at approximately 9:00pm on 12-25-23, R1 approached R2 and continued with this verbalization towards R2. R2 responded by pushing R1 to the ground.

Based on interviews and incident report, Administrator called 911. Paramedics arrived as well as local law enforcement. According to incident report and Administrator, R1 refused to go with paramedics to the hospital, and law enforcement counseled R1 on the dangers of fighting with other residents. No injuries reported by either party.

Additional record reviews of R1 and R2 indicate needs and service plans have been updated to reflect behaviors and includes other interventions in place.

As a result of today's case management, no citations are issued. An exit interview was conducted with Administrator and a copy of this report was provided to Administrator.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/21/2024
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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