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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005745
Report Date: 08/08/2022
Date Signed: 08/14/2022 03:57:44 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220617103753
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: 5DATE:
08/08/2022
UNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:GeneviveTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff do not distribute medications as prescribed
INVESTIGATION FINDINGS:
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Based on records reviewed and interviews conducted the facility's records indicated that the residents did not receive medication on multiple days. The facility uses a Medication Administration Record (MAR) which has blank dates for multiple days in June of 22 and July of 22. Interviews conducted confirmed that the residents missed medication on the days that are blank on the MARs for June and July of 2022 that were provided by the facility.

Based on records reviewed and interviews conducted, the preponderance of evidence standards has been met, therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D during this visit.

Exit interview, Appeal Rights given.
Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20220617103753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 397005745
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/09/2022
Section Cited
CCR
80075(b)
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80075 Health Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.
This requirement is not met as evidenced by: LPA reviewed documentation, interviewed staff and residents. The MARs had blank areas without explanation.
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Licensee will send CCL a copy of medication training for all staff that passmedication. Proof of correction due to CCL by 8/09/2022.
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This poses an immediate health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/17/2022 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220617103753

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: 5DATE:
08/08/2022
UNANNOUNCEDTIME BEGAN:
12:59 PM
MET WITH:GeneviveTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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9
Staff do not properly supervise residents
Staff do not meet residents' dietary needs
INVESTIGATION FINDINGS:
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Allegation: Staff do not properly supervise residents

Based on interviews with the Staff, Residents and the Administrator the facility has staffed the facility with a live-in staff and other relief staff. Staff interviewed confirmed that the facility has live-in staff that are available all times, they also confirmed that the Administrator /Licensee will provided relief for the live-in staff as well as the Licensee's son who is also a staff member.

The information in the allegation for the date of the 16th of June 2022, confirmed that medications were missed, however, the staff schedule show that there were staff on duty that covered the alleged time when staff was sleeping and off work.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20220617103753
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 397005745
VISIT DATE: 08/08/2022
NARRATIVE
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Allegation: Staff do not meet residents' dietary needs

Based on records reviewed and interviews conducted the facility has a menu that is being followed by the Staff, Staff will take pictures of the meals that are prepared and saves the photos for evidence that the facility is following the menu. LPA was given a copy of the photos taken by staff of the meals that were prepared and a copy of the menu.

Residents interviewed confirm that they will eat at fast food places on occasion, not because food is not available; they stated that "sometimes they want fast food."

Based on information obtained in this investigation the complaint is unsubstantiated, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4