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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700402
Report Date: 10/20/2023
Date Signed: 10/24/2023 05:49:44 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 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
08/01/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230801105218
FACILITY NAME:WELDWOODSFACILITY NUMBER:
392700402
ADMINISTRATOR:ETIM, BOKIMEFACILITY TYPE:
735
ADDRESS:1490 PELUSA LNTELEPHONE:
(510) 470-2881
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:6CENSUS: 4DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Bokime EtimTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff mishandled a client while in care
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 10/20/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Bokime Etim at this time. A brief interview was conducted with the facility designated Administrator at this time.
Current census was 4 residents.
The purpose of this complaint visit was to deliver the findings of this investigation to this facility and it's representative(s) at this time.
Based on interviews and information gathered during the course of this investigation, it was learned that there was an incident that took place on, or around, 07/25/2023 when R1 left the facility without prior notice to the facility staff. Facility staff attempted to locate R1 while driving throughout the neighborhood and the local police were also notified. It was learned that R1 was eventually located and the police were able to talk R1 into returning to this facility without any further incident.
Based on interviews conducted throughout the course of this investigation, it was learned that there weren't any incidents of staff mishandling the resident while in care nor has there ever been any reported incidents
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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 2
Control Number 27-AS-20230801105218
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: WELDWOODS
FACILITY NUMBER: 392700402
VISIT DATE: 10/20/2023
NARRATIVE
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of any form of physical mishandling by facility staff unto R1.

As a result of this investigation, this Department found the allegation to be UNSUBSTANTIATED. A complaint allegation finding of Unsubstantiated meant that although the allegation 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 at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2