397005745-8-12-2025-27-AS-NWPN-DKGUR9-20250812154821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 397005745
Report Date: 08/12/2025
Date Signed: 08/12/2025 03:48:33 PM

Document Has Been Signed on 08/12/2025 03:48 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 HOME		FACILITY NUMBER:	397005745
ADMINISTRATOR/ DIRECTOR:	KOKUMO, ADETAYO		FACILITY TYPE:	735
ADDRESS:	4327 ROMA LANE		TELEPHONE:	(209) 983-5040
CITY:	STOCKTON	STATE: CA	ZIP CODE:	95206
CAPACITY: 6		CENSUS: 5	DATE:	08/12/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Adetayo Kokumo		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 8/12/25, at 11:00 am Licensing Program Analyst (LPA) Noel Wolf Petersen arrived unannounced to conduct the annual inspection, the LPA met with staff ibrahim and was joined by administrator Adetayo kokumo. The LPA explained the purpose of the visit. TKA's guest home is a 4 bedroom 2 bath facility with a capacity of 6 adults aged 18-59. There are 5 current residents and 0 have restricted conditions. The facility has the apropprote exceptions and waivers. Physical Plant was inspected, including but not limited to the kitchen, common areas, storage areas, client bedrooms, client bathrooms, exteriors and evacuation routes. Entryway has required posters of the correct dimension, excepting the personal rights poster. The administrator resolved to print one and hang it up. Staff room has lockable toxic and sharp storage. Common areas have furniture in good repair and have ample space for activites. Storage areas have 2days perishable and 7 days nonperishable foods, LPA pointed out a can that was dented, administrator was receptive to getting rid of any dented foods. client bedrooms are in good repair, LPA let the administrator know about bed bug plastic encasements, they were receptive to aquiring them. Bathrooms have wash water delivered within 105-120*f and have hardware in good repair. Smoke/co alarm is functional, but it is chirping for low battery, which is annoying to and disliked by the residents, and disrupts thier sleep. Licensee is in the process of acquiring a ladder to get to the alarm, having already bought fresh alarms and batteries. Licensee should take a picture of the newly installed alarm and send it to the LPA by end of buisness tomorrow, 8/13/25. Continued on C. Page.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/12/2025

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there were 2 staff interviews and 2 client interviews, documented via 812.

3 staff records were reviewed, they were have required backround checks, firstaid/cpr.

5 client records were reviewed, they have 602 preappraisals, safegaurded property, personal rights, and mar documentation is up to date and in order with the amount of drugs held for 2 clients at random, the files are complete, excepting that the admission agreement contains prohibited language and is missing many required elements, the LPA is asking for a draft of either an entirely new admission agreement or a series of ammdendums and the agreement from the behavior hospital thats currently in use to be sent via Email to the LPA by 8/19/25: noel.wolfpetersen@gmail.com.

The LPA printed a copy of Section 80068 and section 85068, and pointed out a 2005 admission agreement sample to guide the process.

3 Administrator files have to be sent to the LPA: control of the property(a lease agreement), and a copy of the liabaility insurance, and the new or supplemented admission agreement by the above date. The facility is not holding cash and does not have a surety bond. the facility sketch, evacuation control plan, and infection control plan are present and up to date.

no citations were issued as part of this visit, an exit interview was conducted and a copy of the report was left with the licensee.

NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Noel Wolf Petersen
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2025

LIC809 (FAS) - (06/04)

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