<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700391
Report Date: 01/27/2022
Date Signed: 01/27/2022 03:39:00 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2022 and conducted by Evaluator Michael Bilger
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220126113038
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:
01/27/2022
UNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Adetayo KokumoTIME COMPLETED:
02:55 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Unlawful Eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 1-27-22 at 1:56pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to open and investigate complaint allegation noted above. LPA met with Administrator Adetayo Kokumo and explained the purpose of the visit. LPA interviewed Administrator and reviewed facility admission agreement for resident1 (R1), physician report for R1, and requested copy of pre-admission appraisal for R1. LPA also interviewed hospital case manager. Based on interview and record review it was determined that R1 was discharged to the hospital on 1-24-22 and was not intended to be accepted back when ready for return. Upon further interview, it was determined that a 30-day notice was not issued in accordance with Title 22 regulations and per admission agreement.

Based on interview and record review, it is determined that the preponderance of evidence standard is met. Therefore, this allegation is SUBSTANTIATED. Deficiencies are cited under Title 22 regulations, Division 6, Chapter 8. An exit interview was conducted with Adetayo Kokumo and a copy of this report was left with Kokumo. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 27-AS-20220126113038
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2022
Section Cited
CCR
87224(a)
1
2
3
4
5
6
7
Eviction Procedures. The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee will issue a formal 30-day notice to R1 and R1s responsible party. Licensee to submit copy of 30-day notice to LPA by POC due date.

Licensee will read regulation 87224 and submit a signed statement of understanding to LPA by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, R1 was sent to hospital without intention to be accepted back. Licensee did not issue a 30-day notice to R1 in accordance with Title 22 regulation and per facility's admission agreement. This poses a potential health, safety, and resident rights risk to residents in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2