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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005745
Report Date: 02/10/2023
Date Signed: 02/28/2023 03:29:10 PM

Document Has Been Signed on 02/28/2023 03:29 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:
02/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:TayoTIME COMPLETED:
02:58 PM
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Licensing Program Analyst Albert Johnson arrived to conduct an unannounced Case Management visit. LPA met with Staff.

Community Care Licensing received incident reports regarding an AWOL. LPA requested residents files for review. LPA spoke with Administrator regarding the incident reports.

LPA did obtained copies of resident records. R1 is allowed to go into the community without assistance. This is identified in R1's Physician's report. R1 is allowed to go into the community without assistance.

Per California Code of Regulations and Health and Safety Code, Title 22.

No deficiencies were issued today.

Exit interview. Copy of report provided to facility representative.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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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