392700402-11-7-2022-27-AS-KHOS-CKZNUG-20221109094618

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 392700402
Report Date: 10/26/2022
Date Signed: 11/07/2022 03:21:11 PM

Unsubstantiated

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
06/27/2022 and conducted by Evaluator Charlie Yang

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220627090045

FACILITY NAME:	WELDWOODS		FACILITY NUMBER:	392700402
ADMINISTRATOR:	ETIM, BOKIME		FACILITY TYPE:	735
ADDRESS:	1490 PELUSA LN		TELEPHONE:	(510) 470-2881
CITY:	MANTECA	STATE: CA	ZIP CODE:	95337
CAPACITY:	6	CENSUS: 3	DATE:	10/26/2022
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Bokime Etim		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff inappropriately restrained a client while in care

Staff demonstrates inappropriate forms of punishment towards a client

INVESTIGATION FINDINGS:

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Unannounced complaint 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. Brief interview was conducted with the facility designated Administrator.
Current census was 3 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility and it's facility designated Administrator.
Based on a review of the facility forms and documents related to the facility residents, specifically for R1, it was learned that excessive behaviors, aggression, and property destruction were ongoing for this particular resident. A review of the Individual Program Plan (IPP), completed and dated on 07/14/2021 for R1, indicated that R1 was quick to temper and would also falsify statements if R1 did not get R1's way. This would include aggression towards staff and fellow residents. In addition, behaviors such as throwing items out of anger with whatever items were available and throwing oneself at walls and staff during the heat of an outburst were well documented.

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220627090045

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: WELDWOODS	FACILITY NUMBER: 392700402
	VISIT DATE: 10/26/2022

NARRATIVE

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A review of the incident reports and special events involving R1 detailed a history of R1 overloading the electrical capacity for this facility. Once the electrical limit had been exceeded, the breakers for the room that R1 occupied would trigger a shut off in order prevent any fire hazards.
These events of the breakers being set off would trigger R1 into outbursts. These outbursts would be targeted towards R1's roommate or facility staff when they attempted to redirect with aggression and profanity. These events would later be portrayed as a form of punishment by R1.
Based on interviews, it was learned that this facility did not participate, or engaged, in hands on techniques in dealing with violent and aggressive residents. This facility would evacuate the facility residents in close proximity to the aggressor and maintain a safe distance until the behavior de-escalated. There weren't any reported cases where facility staff had to physically restrain any resident while in care at this facility.

As a result of this investigation, this Department found the allegations to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegations may have happened or was valid, there was not a preponderance of the evidence to prove that the alleged violation occurred.

There were no deficiencies observed or cited during todays complaint visit at this time.

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

LIC9099 (FAS) - (06/04)

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