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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005745
Report Date: 05/17/2023
Date Signed: 05/24/2023 10:52:08 AM

Document Has Been Signed on 05/24/2023 10:52 AM - 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:
05/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:16 PM
MET WITH:Tayo K.TIME COMPLETED:
03:45 PM
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LPA Johnson arrived at the care facility unannounced to conduct a case management visit into an incident report received on 05/13/2023.

R-1 AWOL'd from the facility on 5/13/23 and returned on 5/15/2023. According to R1's Physicians report, R1 is allowed to leave the facility unassisted.

LPA spoke with Staff about the facilities care plan for R1 going forward. At this time there is no intervention plan in place to address this behavior.

No deficiencies were cited on today's date.

Exit interview conducted.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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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