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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 392700402
Report Date: 09/10/2025
Date Signed: 09/11/2025 08:13:07 PM

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
06/11/2025 and conducted by Evaluator Charlie Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250611172221
FACILITY NAME:WELDWOODSFACILITY NUMBER:
392700402
ADMINISTRATOR:ETIM, BOKIMEFACILITY TYPE:
735
ADDRESS:1490 PELUSA LNTELEPHONE:
(510) 470-2881
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY:6CENSUS: 3DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Bokime EtimTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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Unannounced complaint visit made out to this facility on 09/10/2025 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 3 residents, of which, one of the residents was out of this facility at their respectable day program at this time.
The purpose of this visit was to present the findings of this investigation to this facility, and its representative, at this time.
Based on interviews conducted during the course of this investigation, it was learned that R1 was discharged from this facility and was placed at an alternate location with the assistance of Valley Mountain Regional Center (VMRC). It was learned that all of R1's personal belongings, medications, and personal items were discharged with R1 at that time.
It was learned that upon arrival to the new location, R1 did not have a corresponding Medication Administration Record (MAR) with R1 at the time of admission so the new staff were concerned about the
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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 2
Control Number 27-AS-20250611172221
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: 09/10/2025
NARRATIVE
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types, quantity, and dispensing history of R1's medications at that time.
The new facility staff reached out to this facility and had to request an updated Medication Administration Record (MAR) in order to compare the information against the medications to make sure that they were accurate in name, quantity, and count.
Based on interviews conducted, it was learned that the medications were being dispensed as prescribed but only that the Medication Administration Record (MAR) did not properly accompany R1 to the new placement. This facility, and it's representative, did eventually send over the updated MAR to the new location where R1 was placed.

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: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2