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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850004
Report Date: 12/06/2022
Date Signed: 12/06/2022 06:48:34 PM


Document Has Been Signed on 12/06/2022 06:48 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:YOKAM'S RCFE #1FACILITY NUMBER:
425850004
ADMINISTRATOR:KAMTO, YOLANDE KONGUEP T.FACILITY TYPE:
740
ADDRESS:958 E TUNNELL STTELEPHONE:
(805) 922-7670
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY:0CENSUS: 0DATE:
12/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
06:15 PM
MET WITH:Alphonse Kamato, LicenseeTIME COMPLETED:
06:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Olson conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control #29-AS-20220603150229). LPA conducted a telephonic visit with former Licensee Representative Alphonse Kamato. The purpose of the visit is to issue a citation for a deficiency observed during the complaint investigation. The facility closed due to a change of ownership effective 01/12/2022.

During the complaint investigation of complaint #29-AS-20220603150229, the following deficiency was observed:

Based on the 01/27/2021 physician report, R1 had no capacity for self-care which indicates R1 depended on others for all activities of daily living. The licensee did not submit an exception request for the prohibited health condition.

Citation issued, exit interview conducted, copy of report and appeal rights were emailed and mailed to Licensee.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
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 2


Document Has Been Signed on 12/06/2022 06:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: YOKAM'S RCFE #1
FACILITY NUMBER: 425850004

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited

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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition...shall not be admitted or retained...(5) Residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.
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This requirement is not met as evidenced by: Based on the 01/27/2021 physician report, R1 had no capacity for self-care which indicates R1 depended on others for all activities of daily living. The licensee did not submit an exception request to admit/retain R1, which posed an immediate health and
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safety risk to residents 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.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Jeannette OlsonTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 12/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2