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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 10/26/2022
Date Signed: 11/01/2022 03:30:32 PM

Document Has Been Signed on 11/01/2022 03:30 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:WELDWOODSFACILITY NUMBER:
392700402
ADMINISTRATOR:ETIM, BOKIMEFACILITY TYPE:
735
ADDRESS:1490 PELUSA LNTELEPHONE:
(510) 470-2881
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 3DATE:
10/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bokime EtimTIME COMPLETED:
01:00 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
Unannounced annual visit made out to this facility on 10/26/2022 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Bokime Etim, who was briefly interviewed at this time.
This facility was licensed to accept and retain up to 6 residents at any given time. This facility was also vendorized through Valley Mountain Regional Center.
Current census was 3 residents of which all 3 were out of the facility at this time. It was learned that they were out at their respectable day programs or school.
Tour of this facility was conducted.
A tour of the facility resident rooms was conducted. Resident furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Resident restrooms were toured and observed to be able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees at this time.
Kitchen area was toured. Cabinets and drawers were reviewed.
Medication cabinets were observed to be present and properly locked to make them inaccessible to the residents at all times. Policies and procedures were discussed with the facility designated Administrator in terms of dispensing, documenting, and overall administration of resident medications.
First aid kits were observed to be present and contained all of the necessary components at this time.
Policies and procedures were discussed in relation to narcotics and medications that required a separate count and documentation by incoming staff and outgoing staff. A review was conducted in regards to this documentation of the resident narcotics.
Living area, dining area, and all other areas intended for resident use were toured and observed to be in compliance at this time.
Fire extinguishers, located in the living area and other areas throughout this facility, were observed to have been annually inspected by the local fire extinguisher company, Armor Fire, on 06/06/2022 and in
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: WELDWOODS
FACILITY NUMBER: 392700402
VISIT DATE: 10/26/2022
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
26
27
28
29
30
31
32
compliance at this time.
Laundry area was toured. Chemicals, detergents, and bleaches were observed to be locked and made inaccessible to the residents at this time.
A review of the food supply was conducted to make sure that there was a sufficient amount of 2-day perishable and 7-day nonperishable quantities at all times.
Garage area was toured. Additional food storage unit was observed to be present and functional at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2