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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005745
Report Date: 09/02/2021
Date Signed: 09/08/2021 02:23:05 PM

Document Has Been Signed on 09/08/2021 02:23 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:
397005745
ADMINISTRATOR:KOKUMO, ADETAYOFACILITY TYPE:
735
ADDRESS:4327 ROMA LANETELEPHONE:
(209) 983-5040
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
09/02/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:49 AM
MET WITH:A KokumoTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Albert Johnson conducted a case management to determine if R1 was given a refund for money paid to the facility for the month. LPA talked with Administrator and explained the purpose of today's investigation.

LPA discovered that R1 has been placed in a new facility as of August 17, 2021. She has not resided at (TKAS Guest Home) since August 7, 2021.

The facility received the full amount of her B & C cost of $1,800.00 per month from Jan - May 2021.

In the month following, June - August 2021 The facility received the following payments for R1's care:

Continued
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/02/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 397005745
VISIT DATE: 09/02/2021
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June $ 1600 paid balance owed $200 to Tkas
July $ 1420 paid balance owed $380 to Tkas
Aug $1375 paid $58* 17 days =$987
minus $1375, 987 =$388 to R1

Then $580.00 owed to Tkas for June and July minus from $388.00= $192.00 balance owed Tkas Guest Home

R1 moved all her personal belongings on 17th of August that was the legal date of moving.

No citations given

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 09/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021
LIC809 (FAS) - (06/04)
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