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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 05/17/2023
Date Signed: 05/18/2023 05:03:53 PM

Document Has Been Signed on 05/18/2023 05:03 PM - 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
05/17/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ngozi EtimTIME COMPLETED:
01:00 PM
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Unannounced case management visit made out to this facility on 05/17/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility representative, Ngozi Etim, who was requested by this LPA to go ahead and contact the facility designated Administrator to let him know that CCL was present at this time. It was learned that the facility designated Administrator was at an appointment with a facility resident at this time and was unable to be present.
Brief interview was conducted with the facility representative at this time. Also present was another facility staff member, Ude Etim, at this time.
Current census was 4 residents, of which 3 residents, were out of this facility at their respective day programs at this time. One resident was at an appointment with the facility designated Administrator.
The purpose of this visit was to follow up on an Unusual Incident Report that was submitted into CCL on 04/26/2023 involving resident, R1, and the issues surrounding this resident.
A review of the facility incident report and actions taken by this facility in response to this event was conducted.
A review of the IPP and background information for R1 was conducted as well.

There were no deficiencies observed or cited during today's case management visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2023
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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