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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 05:59:13 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
07/07/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230707100749
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:
03:00 PM
MET WITH:Bokime EtimTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff opened a bank account for client in care without proper authorization

Clients in care are not provided proper food service
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 R1 initiated the idea of wanting to open up their own personal checking/savings account from a banking institution of their own choosing. It was learned that it was the intent of R1 to be able to carry an ATM card so that R1 could use this while attending their day program and also while out on community events and day program supervised outings.
Based on interviews, it was learned that there weren't any concerns about the food and food service that was being provided to the residents in care at this time.
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 5
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
07/07/2023 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230707100749

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:
03:00 PM
MET WITH:Bokime EtimTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not allow client's visitor on facility grounds
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 the facility designated Administrator, from his own admission, did inform a family member of R1 that they were not allowed to be present or enter facility grounds.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
Substantiated
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: 2 of 5
Control Number 27-AS-20230707100749
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
10/27/2023
Section Cited
CCR
85072(b)(4)
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Personal Rights
To have visitors, including advocacy representatives, visit privately during waking hours, provided that such visitations do not infringe upon the rights of other clients.
This Licensee was found to be deficient as evidenced by not allowing a family member
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Facility Administrator stated that a review of the section cited, 85072 Personal Rights, will be conducted with an emphasis on the subsection (b)(4).
A statement of correction will be completed and submitted into CCL by the due date for review by this LPA.
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to visit and informing them of such a decision which posed a potential threat to the Health, Safety, and Personal Rights of the 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230707100749
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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The following deficiencies were observed and cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were printed and a copy was left with the facility designated Administrator 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: 4 of 5
Control Number 27-AS-20230707100749
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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A review of the facility food supply was conducted for 2-day perishable and 7-day non perishable quantities which were observed to be sufficient and able to meet the needs of the residents at this time.

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 were valid, there was not a preponderance of the evidence to prove that the alleged violations 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: 5 of 5