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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 03/19/2025
Date Signed: 03/25/2025 09:51:42 AM

Document Has Been Signed on 03/25/2025 09:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WELDWOODSFACILITY NUMBER:
392700402
ADMINISTRATOR/
DIRECTOR:		ETIM, BOKIMEFACILITY TYPE:
735
ADDRESS:1490 PELUSA LNTELEPHONE:
(510) 470-2881
CITY:MANTECASTATE: CAZIP CODE:
95337
CAPACITY: 6CENSUS: 4DATE:
03/19/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Erica LopezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Unannounced case management visit made out to this facility on 03/19/2025 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility staff person, Erica Lopez, who was briefly interviewed at this time. This LPA requested that the staff person go ahead and contact the facility designated Administrator, Bokime Etim, who spoke with this LPA over the phone.
Current census was 4 residents.
The purpose of this case management visit was to follow up and obtain additional forms and documents related to residents, R1 and R2, at this time.
The following request was made for this facility to provide the forms and documents as stated below:

LIC 602 for R1 and R2
Needs and Appraisal for R1 and R2
Any, and all, LIC 624s related to R1 and R2 since 01/01/2025
Any, and all, facility progress notes related to R1 and R2
IPPs for R1 and R2
Admission Agreements for R1 and R2

There were no deficiencies observed or cited during today's case management visit since this LPA's sole purpose was to retrieve additional information related to recent incidents that took place in regards to resident R1 and R2.

Exit Interview
NAME OF LICENSING PROGRAM MANAGER: Liza King
NAME OF LICENSING PROGRAM ANALYST: Charlie Yang
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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