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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700402
Report Date: 11/21/2024
Date Signed: 11/27/2024 10:40:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241018163538
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:
11/21/2024
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Bokime EtimTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff engaged in an altercation with resident in care.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 11/21/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Bokime Etim, who was briefly interviewed at this time.
Current census was (4) residents, of which, (1) resident was out of the facility at their respective day program at this time.
The purpose of this visit was to inform this facility, and it's representative, that a complaint investigation has been completed and to deliver the findings at this time.
Based on a review of the forms and documents obtained during the course of this investigation, it was learned that R1 was the aggressor who initiated the altercation that took place on 09/26/2024. The altercation stemmed from a minor dispute over food snacks which then turned physical by R1 after being confronted by the facility designated Administrator about not taking others belongings without their consent. It was learned that the facility designated Administrator Bokime Etim believed that the fire extinguishers,
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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-20241018163538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: WELDWOODS
FACILITY NUMBER: 392700402
VISIT DATE: 11/21/2024
NARRATIVE
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which were hanging on the walls, could possibly be used as a weapon so he grabbed the one in the kitchen area.
It was learned that R1 started to grab the wooden chairs in the dining area and was swinging them at the facility designated Administrator. It was learned that the facility designated Administrator was then using the fire extinguisher to defend himself from the physical assault by R1. After several swings of the chair, R1 would also throw them at the facility designated Administrator too and then go and pick up another one. It was learned that at one point, R1 swung a chair and struck the fire extinguisher which caused it to discharge its contents all over the kitchen area, sitting area, and adjacent living spaces. Copies of photos of this incident of the fire extinguisher after discharging its contents were submitted and reviewed by this LPA.

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: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2