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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700402
Report Date: 04/25/2025
Date Signed: 04/29/2025 05:38:30 PM

Substantiated


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
03/14/2025 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250314121102
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:
04/25/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Bokime EtimTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Licensee does not ensure facility has nonperishable foods for a minimum 7 days and fresh perishable foods for a minimum of 2 days for clients in care.
INVESTIGATION FINDINGS:
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Unnnounced complaint visit made out to this facility on 04/25/2025 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.
The purpose of this complaint visit was to inform this facility, and it's representative, about the findings from this investigation.
Based on a review of the facility food storage unit(s) in the kitchen, it was observed that the perishable food quantities were insufficient and unable to meet the required 2-day supply to be maintained at all times. Based upon a review of the nonperishable food quantities in the kitchen area and pantry, it was observed that there was not a sufficient supply of nonperishable food quantities to meet the 7-day supply that is expected to be maintained at all times.
Based on a review of the facility food storage units in the garage area, it was observed that they did not contain any additional food items to contribute to the overall 2-day perishable and 7-day nonperishable
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2025
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 3
Control Number 27-AS-20250314121102
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: 04/25/2025
NARRATIVE
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food requirements that were to be maintained at all times.

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.

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: 04/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20250314121102
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
04/26/2025
Section Cited
CCR
85076(d)(1)
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The licensee shall meet the following food supply and storage requirements:
Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
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The facility designated Administrator stated that the 2-day perishable and 7-day nonperishable food supply will be maintained at all times.
A statement of correction, along with a food purchase receipt for this facility, will be completed and submitted into CCL by the
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This facility was found to be deficient as evidenced by not having the required 2-day perishable and 7-day nonperishable food quantities at all times which posed an immediate threat to the Health, Safety, and Personal Rights to residents in care.
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due date detailing the types of food and quantity obtained as well.
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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: 04/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3