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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 397005745
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:12:27 PM

Document Has Been Signed on 10/15/2024 03:12 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 HOMEFACILITY NUMBER:
397005745
ADMINISTRATOR/
DIRECTOR:		KOKUMO, ADETAYOFACILITY TYPE:
735
ADDRESS:4327 ROMA LANETELEPHONE:
(209) 983-5040
CITY:STOCKTONSTATE: CAZIP CODE:
95206
CAPACITY: 6CENSUS: 6DATE:
10/15/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Adetayo Kolumo, AdministrstorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Renee Campbell arrived at the facility to conduct an unannounced annual inspection on 10/15/2024.  LPA met with Adetayo Kokumo, Administrator and explained the purpose of the visit.

LPA Campbell inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyard of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) ambulatory residents. Currently, there are 5 clients in residence.  LPA observed the facility to be free of odor and pathways were unobstructed. LPA Campbell observed bedrooms to be properly furnished with appropriate bedding and accessories. There are no bodies of water present. Outside, LPA Campbell observed bagged cans for recycling in the outdoor smoking area and overgrown grass circling the backyard. A small space had been mown recently. Pathways for the backyard and fire exit were clear.

LPA Campbell observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured in the bathroom at 120 degrees Fahrenheit. The bathroom wall had 2 to 3 nickel sized holes and the bathtub was stained. Fire extinguishers (last inspected in February of 2024), smoke and carbon monoxide detectors were successfully tested. The facility thermostat was observed at 72 degrees Fahrenheit. LPA Campbell checked the medication storage and found medication to be locked away and inaccessible to clients. Kitchen cabinets were observed to be darkened at the corners and sticky when touched. The first aid kit was complete and contained bandages, scissors and tweezers. LPA Campbell requested client and staff files for review. LPA reviewed 5 of 5 resident files and 3 of 3 staff files. Resident and staff files were complete. All staff were found to be cleared on Guardian. Toxins and sharps were made inaccessible to clients in care and were kept locked in the staff room.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 10/15/2024
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The following documents will be email to LPA Campbell (Renee.Campbell@dss.ca.gov) by 10/04/2023 by 5:00 PM by end of day:
(1) LIC 308 Designation of Administrative Responsibility
(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate   
(4) LIC 610 Emergency Disaster Plan


Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, deficiency 80087(a) is being cited on the attached 809-D during this visit.  An exit interview was conducted, and copies of the report and appeal rights left. 
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Renee Campbell
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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Document Has Been Signed on 10/15/2024 03:12 PM - It Cannot Be Edited


Created By: Renee Campbell On 10/15/2024 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: TKAS GUEST HOME
FACILITY NUMBER: 397005745

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
80087(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as observed in regards to sticky, dirty cabinets, fixtures covered in dust, bulbs that have not been replaced, a stained tub and small holes in the bathroom wall which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/31/2024
Plan of Correction
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The client wil maintain and repair the items mentioned in the report by the POC due date. Completion will be verified when the licensee sends images of the repairs.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Lisa Rios
LICENSING EVALUATOR NAME:Renee Campbell
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


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