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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005745
Report Date: 06/26/2024
Date Signed: 06/26/2024 01:41:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20240503093727
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:
06/26/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:KOKUMO, ADETAYOTIME COMPLETED:
01:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient food
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the above allegations. LPA was greeted by staff licensee jaind about 20 minutes later. LPA explained the reason for the visit.

LPA Lewis conducted a facility tour and observation. LPA conducted facility tour with administrator LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed to contain no foul odors.Fire extinguisher was full charged and dated 2-26-24. Room temperature was 76*F. Smoke alarms and carbon detectors are functioning properly. Current census is 6. No obstructions to fire exits noted during today's tour. LPA observed a lock on the pantry door to have been turned around and to be unlocked residents are able to opend at will. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. On 5/03/2024 .

Exit interview conducted. Copy of report given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2024 and conducted by Evaluator Kesha Lewis
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240503093727

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:
06/26/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:KOKUMO, ADETAYOTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff speak to clients rude
Infestation of roaches
Facility dirty
medical Appointments missed due to transportation
Meds mismanaged
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to deliver findings for the above allegations. LPA explained the reason for the visit.

LPA Lewis conducted a facility tour and observation. LPA conducted facility tour with administrator LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed to contain no foul odors.Fire extinguisher was full charged and dated 2-26-24. Room temperature was 76*F. Smoke alarms and carbon detectors are functioning properly. Current census is 6. No obstructions to fire exits noted during today's tour. Based on intervies with 4 out of 6 residents and 1 staff members as will as the licensee and LPA Lewis's observation the above allagations are found to be UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened, the preponderance of evidence does not prove it.

Exit interview conducted. Copy of report given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5