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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392700402
Report Date: 09/12/2024
Date Signed: 09/13/2024 10:33:11 AM

Document Has Been Signed on 09/13/2024 10:33 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:
09/12/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Bokime EtimTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Unannounced case management visit made out to this facility on 09/12/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Bokime Etim at this time. An interview was conducted with the facility designated Administrator at this time.
Current census was (4) residents, of which (1), was out of the facility at this time visiting with family.
The purpose of this case management visit was to follow up on an Unusual Incident Report, and subsequent Death Report, for facility resident, R1, which was submitted into CCL on 09/09/2024.

The following forms and documents were requested by this LPA:
  • Current facility resident roster

  • Current LIC 500

  • Current contact information, including phone numbers, for all facility staff


This LPA will review this information and be in touch with the facility designated Administrator if anything else is needed at that time.
This LPA also requested for the complete file for R2 in regards to a separate matter that was just brought forth during this case management visit. This will serve as a receipt for the facility, and it's facility designated Administrator, that this LPA has taken the file for R2 out of this facility at this time. Copies will be made and the file will be returned at a later date.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2024
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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