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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005745
Report Date: 09/24/2024
Date Signed: 09/24/2024 02:43:02 PM

Unsubstantiated


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
07/11/2024 and conducted by Evaluator Kesha Lewis
COMPLAINT CONTROL NUMBER: 27-AS-20240711103246
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: 5DATE:
09/24/2024
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:KOKUMO, ADETAYOTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff does not ensure food of good quality is being provided to clients in care.
Staff do not ensure facility is kept in safe, sanitary conditions for clients in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kesha Lewis arrived at the facility unannounced to a complaint for the above allegations. LPA was greeted by staff. LPA explained the reason for the visit.

LPA Lewis conducted a facility tour and observation. LPA conducted facility tour with staff LPA observed facility common areas, various resident rooms, kitchen area and hallways. Facility was observed to contain no foul odors and new furniture was present. room temperature was 81*F. Smoke alarms and carbon detectors are functioning properly. Current census is 5. No obstructions to fire exits noted during today's tour. LPA interviewed R1-R2
see 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
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-20240711103246
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: TKAS GUEST HOME
FACILITY NUMBER: 397005745
VISIT DATE: 09/24/2024
NARRATIVE
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Allegation 1: Staff does not ensure food of good quality is being provided to clients in care and allegation 2: Staff do not ensure facility is kept in safe, sanitary conditions for clients in care are found to be UNSUBSTANTIATED.

Based on the interviews, with R1-R2 and LPA observations of the facility on multiple occasions the allegation is deemed Unsubstantiated. Photos of food in the facility were taken.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, no deficiencies are being cited on during this visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Kesha Lewis
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2