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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 11/21/2024
Date Signed: 11/26/2024 08:47:22 AM

Document Has Been Signed on 11/26/2024 08:47 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:
11/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:30 PM
MET WITH:Bokime EtimTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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Unannounced case management visit made out to this facility on 11/21/2024 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, of which, (1) resident was out of the facility at their respective day program at this time.
The purpose of this visit was to deliver the findings of a review that was conducted in regards to a recent death that occurred at this facility. Based on the findings of this review that was conducted, it was deemed that it was "Unsubstantiated" for the following allegation:
  • Neglect/Lack of Care: Lack of care and supervision resulted in choking incident and death of resident.

There were no deficiencies observed or cited in relation to this review and the findings.

In addition, this case management visit was conducted to follow up about the forms and documents that were provided by this facility designated Administrator Bokime Etim in relation to the Plan of Operation (Program Description) and its contents at this time.


It was observed that R1's Needs and Services Plan did not properly reflect their care needs since it had not been updated as required whenever changes took place for R1. Some of the updated care needs that were identified for R1 were not addressed in the form of an updated care plan to make sure that this facility was capable of providing adequate care and supervision for R1.

From a prior visit that was conducted on 10/28/2024, This LPA discovered that the facility designated Administrator was in the process with development and construction of another possible living unit that was taking place in the backyard area of this facility. It was learned that a permit was pulled on 07/22/2024 through the City of Manteca for an Accessory Dwelling Unit (ADU) to be placed behind this facility.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/21/2024
NARRATIVE
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No prior notice was given to this LPA and any CCL regional office in regards to the new construction before it commenced.

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/26/2024 08:47 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/21/2024 at 04:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WELDWOODS
FACILITY NUMBER: 392700402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/22/2024
Section Cited
CCR
80022(d)(2)

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If the licensee intends to admit or care for one or more clients who have a restricted health condition specified in Section 80092, the facility policies and a program description shall be included. At a minimum, the information related to those clients and their needs shall specify all of the following:
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The facility designated Administrator stated that a review of the current Plan of Operation (Program Description) will be conducted and updated. This will be done to address any changes to resident needs, services, and care plans. A statement of correction, along with a copy of the updated Plan of Operation,
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The licensee's plans for serving that client.
This facility was found to be deficient as evidenced by a review of (1) facility resident file which did not have an updated plan by this facility to address the services that would be provided to address these new needs. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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will be completed and submitted into CCL by the due date.
Type A
11/22/2024
Section Cited
CCR80068.3(a)

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The licensee shall ensure that each client's written Needs and Services Plan is updated as often as necessary to assure its accuracy, but at least annually. These modifications shall be maintained in the client's file.
This facility was found to be deficient as evidenced by a review of (1) facility resident
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The facility designated Administrator stated that a review of the current Needs and Services Plans for all current residents will be conducted and updated as necessary. This will be done to address any changes to resident needs, services, and care needs. A statement of correction, along with copies of
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which did not have an updated plan by this facility to address the services that would be provided to address these new needs. This posed an immediate threat to the Health, Safety, and Personal Rights of the residents in care.
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all updated Needs and Services Plans for the current residents, will be completed and submitted into CCL by the due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/26/2024 08:47 AM - It Cannot Be Edited


Created By: Charlie Yang On 11/21/2024 at 04:58 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WELDWOODS
FACILITY NUMBER: 392700402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
11/28/2024
Section Cited
CCR
80086(a)

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Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
This facilty was found to be deficient as evidenced by the discovery of an Accessory Dwelling Unit (ADU) that was under construction in the backyard area without
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This facility designated Administrator stated that an updated LIC 999 for the exterior grounds and buildings will be completed. An updated Plan of Operation will be completed to reflect the addition of the ADU and its purpose for this facility. A review of the rules and regulations related to reporting
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prior notification provided to this LPA or CCL at this time.
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requirements and proper notification to CCL will be conducted and completed. A statement of correction, along with all of the required updated forms and documents, will be completed and submitted into CCL by the due date.

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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.
SUPERVISOR'S NAME:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2024


LIC809 (FAS) - (06/04)
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