<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005745
Report Date: 03/24/2022
Date Signed: 03/24/2022 03:18:53 PM

Document Has Been Signed on 03/24/2022 03:18 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: 4DATE:
03/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Temitope IbitoyeTIME COMPLETED:
03:35 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 3-24-22 at 2:04pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding medication documentation. LPA met with lead caregiver Temitope Ibitoye and explained the purpose of the visit. Administrator Adetayo Kokumo was notified by phone and gave permission for Temitope to sign in her absence. LPA reviewed medication log sheets and centralized storage medication for Resident(R1), R2, R3, and R4. LPA also conducted a health and safety check of facility. Facility is a 6-bed adult residential facility with a current census of 4. Facility has 3 bedrooms and 2 bathrooms. Facility temperature was 73*F and water temperature was within 105*F and 120*F. Facility has adequate food storage. There were no obstructions to fire exits observed by LPA. Facility appears clean and sanitary with no foul odors.

Medication log sheets dated December 2021 to current are completed and accurate at this time. Medications are locked and secured and inaccessible to clients in care. Current physician orders match medications on hand. All toxins and other dangerous materials are inaccessible to clients in care.

As a result of today's visit no deficiencies are cited. An exit interview was conducted with Temitope Ibitoye and a copy of this report was left with Temitope.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Michael Bilger
LICENSING EVALUATOR SIGNATURE: DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/24/2022
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 1