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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 04/17/2024
Date Signed: 04/22/2024 12:45:56 PM

Document Has Been Signed on 04/22/2024 12:45 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 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: 5DATE:
04/17/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Bokime Etim and Ude EtimTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Unannounced case management visit made out to this facility on 04/17/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Bokime Etim, who was briefly interviewed at this time.
The facility designated Administrator had to leave the facility due to other obligations at this time.
This LPA conducted the rest of this visit with the facility staff person, Ude Etim, at this time.
Current census was 5 residents, of which, two were present but the other three residents were out of the facility at this time.
The purpose of this visit was to follow up with the facility designated Administrator to inquire about the recent Special Incident Reports (SIRs) that were submitted into CCL. There were concerns as to the frequency of the submission and the activities that were involved with the SIRs.
It was learned that this facility, and the facility designated Administrator, was working with Valley Mountain Regional Center and Alta California Regional Center, to address these issues at this time. A plan has been approved for possible placement and relocation.
The facility designated Administrator will submit any changes and updates to these relocation plans.

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: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/17/2024
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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