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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 05:51:01 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
11/13/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241113095325
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:
01:30 PM
MET WITH:Bokime EtimTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not have planned activities for residents.
INVESTIGATION FINDINGS:
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Unannounced 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 interviews conducted during this investigation, it was learned that outings were not readily made available to the facility residents. It was learned that sometimes it was due to not having enough staff on site to accommodate for outings. It was learned that not having enough staff for outings and at this facility would make this facility not compliant since the staff to resident ratio that was to be maintained at all times would be insufficient posing a risk to the Health, Safety, and Personal Rights of the residents in care. It was learned that this facility was to maintain a three resident to one staff member ratio at all times whether present at this facility or out in the community on an outing.
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 5
Control Number 27-AS-20241113095325
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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Based on a review of the facility records, it was learned that this facility was placed on a plan for increased monitoring due to the implementation of am informal conference that was held back on 11/22/2024. It was learned that as part of this agreement and increased monitoring for this facility, this facility was expected to provide weekly updates for the outings that were to be scheduled and participated in by the facility residents. These weekly updates were to be completed and submitted into CCL on a monthly basis since its inception on 11/22/2024.
It was learned that the last updates for the scheduled outings and facility resident participation was last performed for the time frame ending in March 2025. It was learned that submissions for these activities and outings updates were only completed for (2) of the (4) residents at that time.
It was learned that this facility was not following the guidelines that were previously laid out in the informal conference in regards to maintaining outings and offering activities to the residents.

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

DATE: 04/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/13/2024 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20241113095325

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:
01:30 PM
MET WITH:Bokime EtimTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Uncleared staff caring and supervising residents.

Improper food storage
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 this facility list of staff and personnel roster, it was learned that certain staff members would use different names, or nicknames, while present at this facility. It was learned that facility residents would also give certain staff members nicknames and would address them as such when they were present at this facility.
Based on a review of the staff who were currently employed and scheduled for shifts at this facility, it was learned that they were all properly fingerprint cleared and properly associated to this facility at this time. It was learned that a certain staff person was called by a different name, S1, but was listed and cleared under
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20241113095325
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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their legal documented name, S2, at this time.
Based on a review of the facility food supplies for 2-day perishable and 7-day nonperishable quantities that this facility was to maintain at all times, it was observed that they were stored in the appropriate food storage units at the appropriate temperatures at this time.
It was observed that this facility maintained a refrigerator/freezer combination unit in the kitchen area. In addition, it was observed that another refrigerator and upright freezer unit was also in use in the garage area of this facility at this time.

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: 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: 4 of 5
Control Number 27-AS-20241113095325
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)
Type A
04/26/2025
Section Cited
CCR
85079(a)(1)(2)
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The licensee shall ensure that planned recreational activities, which include the following, are provided for the clients:
Activities that require group interaction.
Physical activities including but not limited to games, sports and exercise.
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The facility designated Administrator stated that this facility will be staffed accordingly in order to accommodate the outings and activities for the facility residents. A statement of correction, along with updated documentation of the outings provided and resident(s) who participated, will be
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This facility was found to be deficient as evidenced by the lack of documentation as outlined in the informal conference to document outings and activties that were planned and participated in by the residents. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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completed and submitted into CCL by the due date.
A weekly account for all facility residents will be completed and submitted for the outings that were offered and activities that were participated in by them. Submissions are to be made on a monthly basis.
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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: 5 of 5